Fillable Pensioners Dental Services Plan (PDSP) Claim Form

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Pensioners Dental Services Plan (PDSP) Claim Form

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Page 1 of 2
DENT-25555-E-06-17 (G6442-E)
Pensioners’ Dental Services Plan (PDSP)
Claim Form
Approved by the Canadian Dental Association
PROTECTED once completed
• The PDSP is administered by Sun Life Assurance Company of Canada
• Please provide complete information and print clearly
• If you are also a member of the Public Service Health Care Plan (PSHCP) and you wish us to coordinate the processing of dental claims
cov
ered under both plans:
for oral surgery claims complete and sign both a PDSP and a PSHCP claim form and mail them togethe to our Dental Claims Office
(list
ed on the reverse)
for accidental injury claims complete and sign both a PSHCP and a PDSP claim form and mail them together to our Health Claims Office
1 To be completed by Dentist
P
A
T
I
E
N
T
Last Name Given Name
Address Apt.
City Prov. Postal Code
Unique Number Spec. Patient’s Office Account No.
D
E
N
T
I
S
T
Phone No.:
I hereby assign my benefits payable
from this
claim to the named dentist
and authorize payment directly to
him/her.
Signature of Subscriber
For Dentist’s Use Only - For additional information, diagnosis, procedures, or
special consideration.
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 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. I also authorize the communication of information related to the
coverage of services described in this form to the named dentist.
Signature of Patient (Parent/Guardian)
Office Verification/Dentist’s Signature
Date of Service Procedure
Code
Intl
Tooth
Code
Tooth
Surfaces
Dentist’s
Fee
Laboratory
Charge Total Charges
Day Month Year
This is an accurate statement of services
performed and the total fee due and
payable E & OE
TOTAL FEE SUBMITTED
For Plan Administrator Use Only
2 To be completed by member
Member information
Contract number
25555
Preferred language of correspondence
English French
Family member covered by this claim
Relationship
to you
Son Daughter
If child is 21 or over, check whether child is:
Disabled Full-time student
Certificate number
Last name First name Date of birth (yyyy-mm-dd)
– –
Telephone number
– –
Address (street number and name) Apartment or suite City Province Postal code
Unmarried child’s name
Date of birth (yyyy-mm-dd)
– –
|
_______________________________________________
_______________________________________________
|
Spouse’s last name First name Date of birth (yyyy-mm-dd)
– –
For SLF use:
DCF
Clear
|
If no, date of prior placement (yyyy-mm-dd)
– –
Reason for replacement
Date dentist took impression for this treatment
(yyyy-mm-dd)
– –
When did the accident occur? (yyyy-mm-dd)
– –
How did the accident occur?
If yes, date initial appliance was installed (yyyy-mm-dd)
– –
|
Name of insurer Contract number Certificate number
If yes, spouse or common law partner’s date of birth (yyyy-mm-dd)
– –
|
X
Date (yyyy-mm-dd)
– –
Page 2 of 2
3 Details of claim
1. Major restorative or prosthodontic caims (e.g. crowns, inlays, bridges, dentures, etc.)
Is this the initial placement? No Yes
Please ask your dentist to incude the following to facilitate handling of your claim:
• Pre-treatment
x-rays (for crowns, inlays, onlays, veneers and bridges only)
2. Are any expenses the result of an accident? No Yes
If yes, complete the following:
Where did the accident occur?
Work Home Other
Are any expenses the result of a condition covered by Workers’ Compensation/Workplace Safety and Insurance Board? No Yes
3. Orthodontics
Is this treatment for orthodontic purposes?
No Yes
4 Coverage under other benefit plans
Are you covered for any of these expenses under any other benefit plan as an active employee?
No Yes If yes, you must submit a claim to your employee plan first; then attach the original Explanation of Benefits (EoB) from
that plan and complete this claim form.
Are you covered for any of these expenses under any other benefit plan as a pensioner?
No Yes If yes, please indicate:
Is your spouse, common law partner, or child covered for any of these expenses under any other benefit plan?
No Yes
If yes:
• You must submit a claim for your spouse or common law partner to their 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.
• Once the other plan processes the claim, then attach the original Explanation of Benefits (EoB) from that plan and complete this claim form.
5 Member certification and authorization
I certify that the statements in this claim are true and complete and do not contain a claim for any expenses previously paid for
by this or any other plan. I also certify that my covered family members, if applicable, meet the plan eligibility requirements. I
authorize release of any information or record requested in respect of this claim to the Plan Administrator, Sun Life Assurance
Company of Canada to be used for the limited and sole purposes of underwriting, administering and paying claims under the
PDSP. The Plan Administrator may check the accuracy of the information given in support of this claim.
Member signature
Mailing instructions
Mail the completed form to:
Sun Life Assurance Company of Canada
Dental Claims Office
PO Box 6159 STN-CV
Montreal QC H3C 3A7
613-247-5100 or
1-888-757-7427 (toll-free in North America)
DENT-25555-E-06-17 (G6442-E)
For SLF use:
DCF
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Pensioners Dental Services Plan (PDSP) Claim Form

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Completed 5 March 2022

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