Fillable Dental Claim Form 1 | To be completed (Ryerson Polytechnic University)

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Dental Claim Form 1 | To be completed (Ryerson Polytechnic University)

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Country of origin: CANADA
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Page 1 of 2
DENT-E-11-10
3 | Spouse and children covered by this claim – complete this section if claim is for spouse or child
4 | Co-ordination of benefits – complete this section if your spouse and/or children has coverage under any other dental plan or contract
Approved by the Canadian Dental Association
Dental Claim Form
1 | To be completed by Dentist
Last Name Given Name Unique Number Spec. Patient’s Office Account No.
Address Apt.
City Prov. Postal Code
Phone No.:
For Dentist’s Use Only - For additional information, diagnosis, procedures, or I understand that the fees listed in this claim may not be covered by or may exceed my plan
special consideration. benefits. I understand that I am financially responsible to my dentist for the entire treatment.
I acknowledge that the total fee of $ is accurate and has been charged to me for
services rendered. I authorize release of the information in this claim form to my insuring
company / plan administrator.
Duplicate Form
m
Signature of Patient (Parent/Guardian)
Office Verification/Dentist’s Signature
P
A
T
I
E
N
T
I hereby assign my benefits payable
from this claim to the named dentist
and authorize payment directly to
him/her.
Signature of Subscriber
D
E
N
T
I
S
T
For Plan Administrator Use Only
Intl
Date of Service Procedure
Tooth
Tooth Dentist’s Laboratory
Day Month Year
Code
Code
Surfaces Fee Charge Total Charges
This is an accurate statement of services
performed and the total fee due and
payable E & OE
TOTAL FEE SUBMITTED
2 | Information about you – be sure to fully complete this section
Contract number
Member ID number Your plan sponsor/employer
Preferred language of correspondence
m English m French
Your last name First name
m
Male
m
Female
Date of birth (yyyy-mm-dd)
– –
Daytime phone number
– –
Your address (street number and name) Apartment or suite City Province Postal code
Spouse’s last name First name Date of birth (yyyy-mm-dd)
– –
m
Male
m
Female
Child’s name Relationship to you
m Son m Daughter
Date of birth (yyyy-mm-dd)
– –
Complete for overage dependents (refer to benefit information
for age limits)
m
Disabled m Full-time student
Is your spouse or are your children covered for any of these expenses under any other dental plan or contract? m No m Yes
If yes,: •
You must submit a claim for your spouse to his/her plan first.
•
You must submit a claim for your child first under the plan of the parent with the earliest birthday (month and day) in the
calendar year.
If your spouse’s plan is also with us, complete the following:
Contract number Member ID number Spouse’s date of birth (yyyy-mm-dd)
– –
Do you want us to co-ordinate benefits (process both claims)?
m No m Yes
If yes, spouse’s signature
X
Date (yyyy-mm-dd)
– –
For SLF use:
DCF
Clear
25180
Ryerson University
Page 2 of 2
DENT-E-11-10
6 | Authorization and signature – you must complete this section
I certify that all goods and services being claimed have been received by me and/or my spouse or dependents, if applicable.
I certify that the information in this form is true and complete and does not contain a claim for any expense previously paid
for by this or any other plan.
If this claim is being made on behalf of my spouse and/or dependents, I am authorized to disclose information about them,
for the purposes of underwriting, administration and adjudicating claims. I confirm that my spouse and/or dependents, if
any, also authorize Sun Life Assurance Company of Canada (“Sun Life”) to disclose information about their claims to me, for
the purposes of assessing and paying a benefit, if any, and managing my group benefits plan.
I authorize Sun Life and its reinsurers to collect, use and disclose information about me, and if applicable, my spouse
and/or dependents needed for underwriting, administration and adjudicating claims under this Plan to any other
organization who has relevant information pertaining to this claim including health professionals, institutions, investigative
agencies and insurers. I also understand that information pertaining to this claim may be reviewed in the event this Plan
is audited.
In the event there is suspicion and/or evidence of fraud and/or Plan abuse concerning this claim, I acknowledge and agree
that Sun Life may investigate and that information about me, my spouse and/or dependents pertaining to this claim may be
used and disclosed to any relevant organization including regulatory bodies, government organizations, medical suppliers
and other insurers, and where applicable my Plan Sponsor, for the purpose of investigation and prevention of fraud and/or
Plan abuse.
If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable to
me under my benefit plan(s), and the collection, use and disclosure of information about this claim to other persons or
organizations, including credit agencies and, where applicable, my Plan Sponsor for that purpose.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect
for the continued administration of this Plan.
Any reference to Sun Life Assurance Company of Canada or the Plan Sponsor includes their respective agents and service providers.
Member’s signature
X
Date (yyyy-mm-dd)
– –
Respecting your privacy
Your privacy is important to us. We may leverage our strengths in our worldwide operations and in our negotiated relationships with third-
party providers to help us service some of our customers. In some instances our employees, service providers, agents, reinsurers and any of
their service providers, may be located in jurisdictions outside Canada, and your personal information may be subject to the laws of those
foreign jurisdictions.
To find out about our Privacy Policy, visit our website at www.sunlife.ca, or to obtain information about our privacy practices, send a written
request by email to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5.
Questions? Please visit www.sunlife.ca or call our toll-free number 1-800-361-6212 Monday - Friday, 8 a.m. - 8 p.m. ET
5 | Details of claim
If the cost of your treatment will exceed the pre-determination limit in your benefit plan, you should send an estimate to Sun Life
Assurance Company of Canada. To determine if you will be reimbursed for the treatment, have your dentist complete a Pre-Treatment
Form (available from your dentist).
1. Are any expenses the result of an accident?
m No m Yes
If yes, complete the following:
When did the accident occur? (yyyy-mm-dd)
– –
Where did the accident occur?
m Work m Home m Other
How did the accident occur?
Are any expenses the result of a condition covered by a workers’ compensation program?
m No m Yes
2. Is this treatment for orthodontic purposes? m No m Yes Implants? m No m Yes
3. Crowns, Bridges, Dentures Is this the initial placement?
m No m Yes
If No, date of prior placement (yyyy-mm-dd)
– –
Reason for replacement
If Yes, date teeth were extracted (for denture or bridge)
(yyyy-mm-dd)
– –
Please include the following to facilitate handling of your claim: • Pre-treatment x-rays (for crowns, bridges, veneers, inlays, onlays)
• List of all missing teeth (for bridges only)
Mailing instructions – keep a copy of your claim form and receipts for your records
Mail your completed
form to the claims
office nearest you.
Sun Life Assurance Company
of Canada
PO Box 11658 Stn CV
Montreal QC H3C 6C1
Sun Life Assurance Company
of Canada
PO Box 2010 Stn Waterloo
Waterloo ON N2J 0A6
For SLF use:
DCF
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Dental Claim Form 1 To be completed (Ryerson Polytechnic University)

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Completed 20 October 2020

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