Fill - Free fillable Individual Insurance Dental Claim PDF form

Individual Insurance Dental Claim

PART 1 - DENTIST

PART 2 - PLAN MEMBER INFORMATION

GIVEN NAMELAST NAME

ADDRESS APARTMENT

CITY PROVINCE POSTAL CODE

1. PLAN NUMBER

2. YOUR NAME (PLEASE PRINT)

YOUR TELEPHONE NUMBER

YOUR IDENTIFICATION NUMBER

YOUR DATE OF BIRTH (DD/MMM/YYYY)

DATE OF SERVICE

THIS IS AN ACCURATE STATEMENT OF SERVICES PERFORMED AND

THE TOTAL FEE DUE AND PAYABLE, E & OE.

TOTAL FEE SUBMITTED: $

PROCEDURE

CODE

INITIAL

TOOTH

CODE

TOOTH

SURFACES

DENTIST’S FEE

LABORATORY

CHARGE

TOTAL CHARGES

DAY MO. YR.

UNIQUE NO.

OFFICE VERIFICATION

SPEC. PATIENT’S OFFICE ACCOUNT NUMBER

PHONE NUMBER

Manulife

SIGNATURE OF

PLAN MEMBER

SIGNATURE OF PATIENT

(PARENT/GUARDIAN)

CHECK HERE IF TREATMENT PLAN

WHEN A PROPOSED COURSE OF

TREATMENT IS EXPECTED TO COST MORE

THAN $500, IT IS RECOMMENDED THAT

A TREATMENT PLAN BE FILED WITH

MANULIFE INDIVIDUAL INSURANCE.

PRE-TREATMENT X-RAYS ARE REQUIRED

FOR SOME PROCEDURES (E.G. CROWNS

AND BRIDGES).

NAME OF INSURANCE COMPANY

DUPLICATE FORM

FOR DENTIST’S USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS,

PROCEDURES, OR SPECIAL CONSIDERATION.

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 HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM TO THE NAMED DENTIST AND

AUTHORIZE PAYMENT DIRECTLY TO HIM/HER.

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.

Submitting health and dental claims is now easier, faster and better.

On Manulife.ca/SecureServe, you can:

• Easily submit claims online – no more paper or snail mail

• Get reimbursed up to 80% faster with direct deposit – no more waiting for cheques

• See your claims history and benefit eligibility

• And update your contact information

Visit Manulife.ca/SecureServe to register.

Please complete both pages of this form.

The Manufacturers Life Insurance Company Page 1 of 2 CM5001E (11/2020) LH

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PART 4 - PLAN MEMBER CONFIRMATION

PART 5 - STATEMENT OF CONFIDENTIALITY

PART 7 - ACCESSIBILITY AT MANULIFE

PART 6 - MAILING INSTRUCTIONS

BY SUBMITTING A CLAIM TO MANULIFE, I CONFIRM THAT I UNDERSTAND AND AGREE TO ALL OF THE FOLLOWING:

I CERTIFY THAT THE INFORMATION PROVIDED FOR THE CLAIMS BEING SUBMITTED IS TRUE, ACCURATE AND COMPLETE AND THAT I, MY SPOUSE OR

COAPPLICANT AND/OR MY DEPENDENTS HAVE RECEIVED ALL GOODS OR SERVICES OR QUALIFY FOR BENEFITS AS CLAIMED. I UNDERSTAND AND ACKNOWLEDGE THAT

SUBMISSION OF A CLAIM DETERMINED BY MANULIFE TO BE FALSE OR MISREPRESENTED MAY RESULT IN COVERAGE BEING RESCINDED BY MANULIFE WITHOUT FURTHER

NOTICE. I UNDERSTAND AND ACKNOWLEDGE THAT MANULIFE MAY REFER ANY CLAIMS IT HAS DETERMINED WERE FALSELY SUBMITTED TO LAW ENFORCEMENT AUTHORITIES

FOR POSSIBLE PROSECUTION AND MAY PURSUE THE RECOVERY OF ANY MONEY OBTAINED IMPROPERLY THROUGH FALSE CLAIM SUBMISSION. I ALSO AGREE TO REFUND ANY

MONIES OR OVERPAYMENTS THAT I MAY OWE TO MANULIFE IN ACCORDANCE WITH THE PROVISIONS OF MY COVERAGE AND I AUTHORIZE MANULIFE TO DEDUCT SUCH MONIES

FROM MY FUTURE CLAIMS. I AUTHORIZE ANY PERSON OR ORGANIZATION WITH INFORMATION CONCERNING ME, MY SPOUSE OR COAPPLICANT AND/OR MY DEPENDENTS,

INCLUDING ANY MEDICAL AND HEALTH PROFESSIONALS, FACILITIES OR PROVIDERS, PROFESSIONAL REGULATORY BODIES, ANY EMPLOYER, GROUP PLAN ADMINISTRATOR,

INSURER, INVESTIGATIVE AGENCY, AND ANY ADMINISTRATORS OF OTHER BENEFITS PROGRAMS TO COLLECT, USE, MAINTAIN AND EXCHANGE THIS INFORMATION WITH EACH

OTHER AND WITH MANULIFE, ITS SERVICE PROVIDERS, FOR THE PURPOSES OF PLAN ADMINISTRATION, AUDIT AND THE ASSESSMENT, INVESTIGATION AND MANAGEMENT OF

THIS CLAIM. I AGREE A PHOTOCOPY; FACSIMILE OR ELECTRONIC VERSION OF THIS AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL.

The specific and detailed information requested on the Dental Claim form is required to process the insured person’s claim request. To protect the

confidentiality of this information, The Manufacturers Life Insurance Company (Manulife) will establish a “financial services file” from which this

information will be used to process the application, offer and administer services and process claims. Access to this file will be restricted to those Manulife

employees, mandataries, and administrators who are responsible for the assessment of risk (underwriting), marketing and administration of services and

the investigation of claims, and to any other person you authorize or as authorized by law. These people, organizations and service providers may be in

jurisdictions outside Canada, and subject to the laws of those foreign jurisdictions. Your consent to the use of personal information to offer you products

and services is optional and if you wish to discontinue such use, you may write to Manulife at the address shown below. Your file is secured in our offices or

those of our administrator or agent. You may request to review the personal information it contains and make corrections by writing to: Chief Privacy Officer.

Manulife. P.O. Box 1602 Del Stn 500-4-A, Waterloo, Ontario N2J 4C6. A copy of our privacy policy is available on manulife.ca.

Manulife is committed to offering products and services to persons with disabilities, in ways that are consistent with the principles of dignity, independence,

integration and equal opportunity. Manulife has a core belief that everyone should be treated with courtesy and respect and made to feel welcome. Manulife’s

accessibility policy allows you to receive this form in alternate formats upon request. Please contact us at accessibility@manulife.ca, or call us at

1-855-891-8671, if you would prefer this document in an alternate format. If you would like more details about accessibility at Manulife, we would encourage

you to visit our website at manulife.ca/accessibility.

Please mail your completed claim form and receipts to the following address:

Manulife

Individual Insurance – Dental Claims

P.O. Box 670, Stn Waterloo

Waterloo, ON N2J 4B8

Manulife will not assume responsibility for any fees associated with the completion of this form.

SIGNATURE OF PLAN MEMBER DATE (DD/MMM/YYYY)

Manulife, Manulife & Stylized M Design, and Stylized M Design are trademarks of The Manufacturers Life Insurance Company and are used by it, and by its

affiliates under license.

PART 3 - PATIENT INFORMATION

1. PATIENT: RELATIONSHIP TO PLAN MEMBER

DATE OF BIRTH (DD/MMM/YYYY)

2. ARE ANY DENTAL BENEFITS OR SERVICES PROVIDED UNDER ANY OTHER

GROUP INSURANCE OR DENTAL PLAN, ANY TYPE OF

WORKERS’ COMPENSATION BOARD OR GOV’T PLAN?

NO YES

3. IS ANY TREATMENT REQUIRED AS THE RESULT OF AN

ACCIDENT? IF YES, GIVE DATE AND DETAILS SEPARATELY.

4. IF DENTURE, CROWN OR BRIDGE, IS THIS INITIAL

PLACEMENT? GIVE DATE OF PRIOR PLACEMENT AND

REASON FOR REPLACEMENT.

5. IS ANY TREATMENT REQUIRED FOR ORTHODONTIC

PURPOSES?

NO YES

PLAN NUMBER

SPOUSE DATE OF BIRTH (DD/MMM/YYYY)

NAME OF INSURANCE COMPANY

The Manufacturers Life Insurance Company Page 2 of 2 CM5001E (11/2020) LH

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