-
o
o
Date: Location:
Explain how accident happened
PLEASE COMPLETE PAGE 2 OF STATEMENT
2
1
Last name Given name
Address Apt./Suite No.
City Prov. Postal code
Phone No.
$
o
o
o
o o
If no, give date of prior placement and reason for
replacement:
3. If claim is for a denture or bridge, please pr
ovide
missing tooth number(s):
For dentist’s use only, for additional
information, diagnosis, procedures, or
special consideration.
o
Signature of patient (parent/guardian) Office verification
Unique No. Spec. Patient’s office account No.
Signature of subscriber
$
DENTIST
-
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M445D(HSPT-W)-3/20
© 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.
Health SolutionsPlus
Dentalcare Expenses Statement
INSTRUCTIONS
1. Complete page 1 and 2 of this form in full.
2. Sign and date the form.
3. Please retain copies for your files as original receipts will not be returned.
4.
If you wish benefits to be paid directly to the dentist, sign the assignment
portion of P
ART 1 below. Assignment of benefits is irr
evocable.
Canada Life may discuss details of this claim with the assignee.
5. Send to the appropriate Benefit Payment Office for your plan. See
PART 7.
Benefits to be paid from:
Dentalcare Plan Only
Health SolutionsPlus
Both
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.
PART 1 - DENTIST INFORMATION To be completed by Dentist
PATIENT
I hereby assign my
benefits payable from this
claim to the named dentist
and authorize payment
directly to the dentist.
Duplicate form
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 entir
e 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.
Date of Service
Day Month
Year
Procedure
Code
Intl. tooth
Code
Tooth
Surfaces
Dentist
Fees
Laboratory
Charge
Total
Charges
TOTAL FEE SUBMITTED
This is an accurate statement of services performed and the total fee due and payable, e. & o.e.
PART 2 - Claim Details To be completed by Dentist
Please specify
claim details.
1. Is this treatment required as the result
of an accident?
Ye
s
No
If yes, please pr
ovide:
2. If claim is a denture, crown, or bridge, is this initial
placement?
Yes
No
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
0.00
Dentalcare Expenses Statement
Continued (page 2 of 2)
Page 2 of 2 YOU MUST COMPLETE BOTH PAGES
o o
o o
If yes, please provide:
Name of insurance company
Plan number
Plan member I.D. number
Day Month Year
7
3
4
5
Date of birth:
o o
Plan name
Plan number Plan member I.D. number
Last name First name
Number and street
City or town Province Postal code
Day Month Year
Date:
Plan Member signature X
Day Month Year
6
If spouse's plan, please provide spouse's date of birth:
o o o o
Canada Life
M445D(HSPT-W)-3/20
PART 3 - Plan Member Information
You must
complete this
section fully.
If you are
unsure of your
plan name, plan
number or plan
member I.D.
number, please
contact your
plan
administrator.
Plan Member Name
Plan Member Address
Language preference:
English French
PART 4 - Coordination of benefits
Complete this
section to
indicate whether
you or any
member of your
family have
benefits
coverage from
any other plan.
1. Are you, or any member of your family, entitled to benefits under any other plan for the expenses
being claimed? Yes No
2. Is a claim being made for Workers’
Compensation Benefits?
Yes No
PART 5 - Patient information
Complete this
section if claim
is for spouse or
dependant.
Patient name Relationship to
plan member
Date of birth
Day Month Year
If child over 18 years
Does Patient
Reside with Plan
Member?
Yes No
Full time
student
hours
per
week
Yes No
If employed,
how many
hours worked
per week?
PART 6 - Authorization and Signature
I certify that the information given on this claim form is true, correct and complete to the best of my knowledge. I certify that all goods and services being claimed have
been received by me, my spouse and/or my dependents; and that my spouse and/or dependents are eligible under the terms of my plan.
I certify that I am claiming expenses that were incurred by myself or a person(s) for whom I am entitled to claim a medical expense credit under the Income Tax Act
(Canada).
The submission of fraudulent claims is a criminal offence. Canada Life takes the submission of fraudulent claims seriously. Suspected fraudulent claims may be reported to
your employer or plan sponsor and to the appropriate law enforcement agency.
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 benefi ts plan. I authorize Canada Life, any healthcare or dentalcare provider, my plan administrator, other insurance or reinsurance companies,
administrators of government benefi ts or other benefi ts 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 also consent to the use of my personal information for Canada Life and its affi liates’ internal data management and analytics purposes.
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.
PART 7 - Submitting Your Claim
Please send your claim to the Benefit Payment Office below. If blank, please consult your plan administrator for the address.
Health SolutionsPlus Questions?
Call Toll Free: 1.877.883.7072
Winnipeg Benefit Payments
PO Box 3050 Station Main
Winnipeg MB R3C 0E6
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
Clear