,
Please print
UNIQUE NO. SPEC. PATIENT’S OFFICE ACCOUNT NO.
P
LAST NAME GIVEN NAME
D
A
E
T
N
ADDRESS APT.
I
T
E
I
N
CITY PROV. POSTAL CODE
S
T
T
PHONE NO.
SIGNATURE OF SUBSCRIBER
FOR DENTIST’S USE ONLY, FOR ADDITIONAL INFORMATION, DIAGNOSIS
PROCEDURES, OR SPECIAL CONSIDERATION.
SIGNATURE OF PATIENT (PARENT/GUARDIAN)
DUPLICATE FORM
OFFICE VERIFICATION
DATE OF SERVICE
PROCEDURE
INTL.TOOTH
TOOTH DENTIST’S LABORATORY
DAY MO.
FEE CHARGE
TOTAL
YR.
CODE
CODE
SURFACES
CHARGES
THIS IS AN ACCURATE STATEMENT OF SERVICES PERFORMED
AND THE TOTAL FEE DUE AND PAYABLE, E. & O.E.
TOTAL FEE SUBMITTED
Plan Number Division Number Employee Identification Number
Plan Name
Employee Name Date of birth / /
Day Month Year
Employee address
Employee’s Signature
1. Patient’s relationship to you 2. Patient’s date of birth / /
Day Month Year
b) If student, how many hours per week at school?
If yes, name of family member insured Relationship to employee
Name of other insurance company Policy Number
c) If yes to questions 5 a) or b), and the patient is a dependent child, please provide spouse’s Date of Birth / /
Day Month Year
If yes, give date, location, and explain how accident happened
If yes, how many hours worked per week?
If no, give date of prior placement and reason for replacement.
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
STANDARD DENTAL CLAIM FORM
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.
1. Have your dentist complete Part 1.
2. Employee completes Parts 2 and 3.
3.
If you wish benefits to be paid directly to the dentist, sign the
assignment portion of Part 1 above. Assignment of benefits
is irrevocable. Canada Life may discuss details of this claim
with the assignee.
4. Send this claim to:
Questions? Call Toll Free:
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. I ALSO AUTHORIZE THE COMMUNICATION OF INFORMATION RELATED
TO THE COVERAGE OF SERVICES DESCRIBED
IN THIS FORM TO THE NAMED DENTIST.
PART 2 EMPLOYEE INFORMATION
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 benets 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 also consent to the use of my personal information for Canada Life and its afliates’ internal data management and analytics purposes.
I authorize Canada Life, any healthcare provider, my plan administrator, other insurance or reinsurance companies, administrators of government
benets or other benets 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.
PART 3 COORDINATION OF BENEFITS
3. If the patient is a child, does the patient reside with you? Yes No
4. If the child is over 18: a) Is the dependent a full-time student? Yes No
c) Is the dependent employed? Yes No
5. a) Are you or any other member of your family entitled to benefits under any other plan? Yes No
b) Is any member of your family (other than yourself) insured as an employee under this plan? Yes No
6. Is this treatment required as the result of an accident? Yes No
7. Is a claim being made for Worker’s Compensation Benefits? Yes No
8. If claim is for denture, crown or bridge, is this initial placement? Yes No
M445D(WPG)-1/20
© 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.
Date
Winnipeg Benefit Payments
PO Box 3050 Station Main
Winnipeg MB R3C 0E6
