PAGE 1 OF 2 PLEASE COMPLETE PAGE 2 OF STATEMENT
For dentist’s use only, for additional
information, diagnosis, procedures, or
special consideration.
o
and
Signature of patient (parent/guardian) Office verification
Unique No. Spec. Patient’s office account No.
Signature of subscriber
$
DENTIST
-
-
o o
If no, give date of prior placement and reason for
replacement:
3.
If claim is for a denture or bridge, please provide
missing tooth number(s):
o o
Date: Location:
Explain how accident happened
2
1
o
o
o
Last name Given name
Address Apt./Suite No.
City Prov. Postal code
Phone No.
$
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M445D(HCSA-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.
Dentalcare Expenses Statement
With Healthcare Spending Account
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 irrevocable.
Canada Life may discuss details of this claim with the assignee.
5. Send to the appropriate Benefit Payment Office for your plan. See
P
ART 7.
Benefits to be paid from:
Dentalcare Plan Only
Healthcare Spending Account Only
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 underst
that I am financially r
esponsible 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 r
elated 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?
Yes No
If yes, please provide:
2 If claim is for a denture, crown, or bridge, is this initial
placement?
Yes
No
