DENTAL 09/20
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Last Name
Address
City Prov. Postal Code
Apt.
Given Name Unique No.
I hereby assign my benefits payable from this claim to the named Dentist and
authorize payment directly to him/her.
For Dentist’s use only - For additional information, diagnosis, procedures, or
special consideration.
This is an accurate statement of services performed
and the total fee due and payable, E & OE.
1. Patient: Relationship to Plan Member _______________________________ Date of Birth (mm/dd/yyyy) _______________________________________________
If Child, indicate:
Student Handicapped If Student, Indicate School _______________________________________________
2. Are any dental benefits or services provided under any other group insurance or dental plan? Yes No
Any type of workers’ compensation board or government plan?
Plan Contract Number ___________________________________________ Name of Insurance Company ___________________________________________
Spouse Date of Birth (mm/dd/yyyy) ________________________________
3. Is any treatment required as the result of an accident? If “Yes”, give date and details separately. Yes No
4. If denture, crown or bridge, is this initial placement? Give date of prior placement and reason for replacement. Yes No
5. Is any treatment required for orthodontic purposes? Yes No
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
contained in this claim form to my insuring company/plan administrator.
Office verification
SIGNATURE OF
PLAN MEMBER
SIGNATURE OF PATIENT
(PARENT/GUARDIAN)
Spec Patient’s Office Acct. No.
P
A
T
I
E
N
T
D
E
N
T
I
S
T
Phone No.
u
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Standard Dental Claim
SECTION 1: DENTIST INFORMATION
SECTION 2: MEMBER BASIC PERSONAL INFORMATION
SECTION 3: PATIENT INFORMATION
CHECK HERE IF
TREATMENT PLAN
When a proposed course of treatment
is expected to cost more than $500,
a treatment plan must be filed with
OTIP Benefits Services. You will be
advised of the benefits payable under
your plan before treatment begins.
Pre-treatment x-rays are required for
some procedures (e.g. crowns and
bridges).
Date of Service
Procedure
Code
Intl. Tooth
Code
Tooth
Surfaces
Dentist’s Fee
TOTAL FEE SUBMITTED: $
Laboratory
Charge
Total Charges
DAY MO.
YR.
Plan Member Name (First, Middle Initial and Last)
OTIP Identification Number
Plan Number
Date of Birth (mm/dd/yyyy)
Email AddressPlan Sponsor
Direct Deposit
Receive your claim payments faster with direct deposit and enjoy the convenience of seeing your claim statements online.
Visit www.otip.com and log in. Once you have logged in to the Plan Member Secure Site (also known as ‘My Claims’), choose My profile from the top
navigation, then Update banking information. First-time users, you will need to complete registration.
