•
UNIQUE NO. SPEC. PATIENT’S OFFICE ACCOUNT NO.
P
LAST NAME GIVEN NAME
D
A E
T N
I
ADDRESS APT.
T
E I
N S
T
CITY PROV. POSTAL CODE
PHONE NO.
T
SIGNATURE OF SUBSCRIBER
FOR DENTIST’S USE ONLY, FOR ADDITIONAL INFORMATION, DIAGNOSIS,
PROCEDURES, OR SPECIAL CONSIDERATION.
SIGNATURE OF PATIENT (PARENT/GUARDIAN)
OFFICE VERIFICATION / DENTIST’S SIGNATURE
DUPLICATE FORM
n
DATE OF SERVICE
INTL.
PROCEDURE
TOOTH
TOOTH DENTIST’S LABORATORY TOTAL
DAY MO. YR. CODE CODE SURFACES FEE CHARGE CHARGES
THIS IS AN ACCURATE STATEMENT OF SERVICES
PERFORMED AND THE TOTAL FEE DUE AND PAYABLE, E.&OE.
TOTAL FEE SUBMITTED
(please print)
1. Employee’s Full Name Plan Number Employee’s Certificate Number
CF
Employee’s Address
2. Relationship of patient to employee Patient’s Date of Birth
Day Month Year
n n
n n
Name of educational institution
n n
n n
NAME OF PERSON COVERED POLICY NO. AND I.D. NO. NAME OF DENTAL PLAN / OTHER INSURANCE CO.
6. If yes to question 5, and patient is a dependent child, give employee’s birthday (day/month): / / and
birthday of spouse or common-law partner (day/month): / /
n n
If yes, give date, location, and explain how accident happened
n n
n n
If no, give date of prior placement and reason for replacement.
Employee’s Signature Date:
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
ADMINISTRATORS
FOR:
PUBLIC SERVICE
DENTAL CARE PLAN
INSTRUCTIONS
All claims under this group benefits plan are submitted through
the plan member. We may exchange personal information about
claims with the plan member and a person acting on their behalf
when necessary to confirm eligibility and to mutually manage the
claims. A plan member may be asked by Canada Life to provide
document(s) supporting the eligibility of a dependant based on a
random selection of current claims.
1. Have your Dentist complete Part 1.
2. Complete all questions in Part 2.
3. SEND THIS CLAIM TO:
MEMBERS
POSTED
OUTSIDE
CANADA:
Canada Life Health & Dental Benefits
Foreign Benefit Payments
PO Box 6000
Winnipeg MB R3C 3A5
QUEBEC
RESIDENTS
OTHER THAN
NATIONAL
CAPITAL
REGION
Montreal Benefit Payments
Place Bonaventure
800 de la Gauchetière Street. W
Suite 5800
Montreal QC H5A 1B9
OTHER
CANADIAN
RESIDENTS:
Winnipeg Benefit Payments
PO Box 6025 Station Main
Winnipeg MB R3C 3C7
1-855-415-4414 www.canadalife.com
Deaf or hard of hearing and require access to a
telecommunications relay service?
Please contact us: TTY to Voice: 711
Voice to TTY: 1-800-855-0511
PART 1 DENTIST
I HEREBY ASSIGN MY BENEFITS PAYABLE
FROM THIS CLAIM TO THE NAMED DENTIST
AND AUTHORIZE PAYMENT DIRECTLY TO
THE DENTIST.
I UNDERSTAND THAT THE FEES LISTED IN THIS CLAIM MAY NOT BE COVERED BY OR MAY EXCEED MY
PLAN 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 CONTAINED IN THIS CLAIM
FORM TO MY INSURING COMPANY/PLAN ADMINISTRATOR.
PART 2 EMPLOYEE
Is the patient a handicapped
dependent child age
21 or over? Yes No
3. If a dependent child between 21 & 25 years old, is the child a full-time student? Yes No
4. If a common-law partner, has the relationship existed for at least one year? Yes No
5. Are you or any of your dependants entitled to benefits as an employee under this plan or any other group plan? Yes No
7. Is treatment required as the result of an accident? Yes No
If yes, are you a member of the Public Service Health Care Plan? (include copy of benefit payment from the Health Care Plan). Yes No
8. If claim is for denture, crown or bridge, is this an initial placement? (Provide pre-treatment x-rays for crown or bridge). Yes No
At Canada Life, we recognize and respect the importance of privacy. Personal information that we collect will be used for the purposes of assessing your claim and administering the group benefits plan. For a
copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect to service providers), write to Canada Life’s Chief Compliance Officer or refer
to www.canadalife.com.
I authorize Canada Life, any healthcare provider, my plan administrator, other insurance or reinsurance companies, administrators of government benefits or other benefits programs, other organizations, or service
providers working with Canada Life, located within or outside Canada, to exchange personal information when necessary for these purposes. I understand that personal information may be subject to disclosure
to those authorized under applicable law within or outside Canada. I certify that the information given is true, correct, and complete to the best of my knowledge.
HAVE YOU COMPLETED ALL SECTIONS OF THIS CLAIM FORM?
M445D(PSP)-8/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
Any modification of this document without the express written consent of Canada Life is strictly prohibited.
