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STANDARD DENTAL CLAIM FORM201112911410

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STANDARD DENTAL CLAIM FORM201112911410 Powered By Docstoc
					                                                                               The EQUITABLE LIFE insurance company
                                                                                      OF CANADA
                                                                                 One Westmount Road North • PO Box 1603 Stn Waterloo
                                                                                                                                                  STANDARD DENTAL
                            Canadian Life and Health
                            Insurance Association Inc.
                                                                           ®
                                                                                                 Waterloo, Ontario N2J 4C7
                                                                                    tel no: (519) 886-5110       fax no: (519) 883-7403              CLAIM FORM
                                                                               UNIQUE NO.         SPEC.         PATIENT'S OFFICE ACCOUNT NO.     I HEREBY ASSIGN MY BENEFITS PAYABLE FROM
PART 1 DENTIST                                                                                                                                   THIS CLAIM TO THE NAMED DENTIST AND AU-
                                                                                                                                                 THORIZE PAYMENT DIRECTLY TO HIM/HER.
         LAST NAME                                         GIVEN NAME               NAME
 P                                                                             D
 A       _______________________________________________________________       E
 T                                                                             N    ADDRESS
         ADDRESS                                                   APT.
 I                                                                             T
 E       _______________________________________________________________       I    POSTAL CODE
 N       CITY                         PROV.              POSTAL CODE           S
 T                                                                             T                                                                  _________________________________________
                                                                                    TELEPHONE NO.                                                    SIGNATURE OF SUBSCRIBER (INSURED)

FOR DENTIST'S USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES OR SPECIAL                        I UNDERSTAND THAT THE FEES LISTED IN THIS CLAIM MAY NOT BE COVERED OR MAY
CONSIDERATION                                                                                                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.
                                                                                                                                                _________________________________________
                                                                                                                                                 SIGNATURE OF PATIENT (PARENT/GUARDIAN)
                                                                                                             OFFICE VERIFICATION

DUPLICATE FORM
                                          INTL.                                                                        TOTAL
DATE OF SERVICE      PROCEDURE                       TOOTH              DENTIST'S              LABORATORY
                                         TOOTH
DAY     MO    YR.      CODE              CODE       SURFACES              FEE                    CHARGE                                                    FOR CARRIER USE




THIS IS AN ACCURATE STATEMENT OF SERVICES PER-
FORMED AND THE TOTAL FEE DUE AND PAYABLE E. & OE.            TOTAL FEE SUBMITTED
 INSTRUCTIONS FOR CLAIM SUBMISSION
1.    HAVE YOUR DENTIST COMPLETE PART I.
2.    AFTER PART I IS COMPLETE, SIGN PART I ACKNOWLEDGING DENTIST'S FEE.
3.    COMPLETE PART 2 AND 3 IN FULL. INCOMPLETE INFORMATION WILL DELAY THE PROCESSING OF YOUR CLAIM.
4.    SUBMIT THE CLAIM TO YOUR GROUP PLAN ADMINISTRATOR TO COMPLETE PART 4 AND SUBMIT THE CLAIM TO EQUITABLE LIFE.

 PART 2 - EMPLOYEE/PLAN MEMBER/SUBSCRIBER
1. GROUP POLICY/PLAN NO. ________________________________________________________                         2. INSURED'S NAME (PLEASE PRINT) ________________________________________________

     DIVISION (IF APPLICABLE) ______________________________________                                        INSURED'S CERT. NO. OR S.I.N.

     EMPLOYER_____________________________________________________________________                          INSURED'S DATE OF BIRTH (D / M / Y) __________________________________


PART 3 - PATIENT INFORMATION
1. PATIENT: RELATIONSHIP TO EMPLOYEE/PLAN MEMBER/SUBSCRIBER                                            3.   IS ANY TREATMENT REQUIRED AS THE RESULT OF AN ACCIDENT?             NO          YES
                                                                                                            IF YES, GIVE DATE AND DETAILS SEPARATELY.
     ________________________________________________________________________________
     DATE OF BIRTH ___________________________________                                                      a) ARE ANY DENTAL BENEFITS OR SERVICES PROVIDED UNDER
                         DAY        MONTH         YEAR                                                         ANY OTHER GROUP INSURANCE OR DENTAL PLAN?                        NO          YES
                                                                                                               (ie. School Insurance, Workers' Compensation, etc.)
     IF CHILD INDICATE                  STUDENT                    HANDICAPPED
     IS HE/SHE ATTENDING SCHOOL FULL TIME?                 NO              YES                         4.   IS THIS CLAIM THE RESULT OF A MOTOR VEHICLE ACCIDENT?               NO          YES
     IF STUDENT, INDICATE SCHOOL ____________________________________________________
                                                                                                       5.   IF DENTURE, CROWN OR BRIDGE, IS THIS INITIAL PLACEMENT?             NO          YES
     WHEN WILL HIS/HER SCHOOLING BE COMPLETED? ___________________________________                          GIVE DATE OF PRIOR PLACEMENT AND REASON FOR REPLACEMENT.
     IS HE/SHE EMPLOYED FULL TIME?                         NO              YES
                                                                                                       6.   IS ANY TREATMENT REQUIRED FOR ORTHODONTIC PURPOSES?                 NO          YES
     IS HE/SHE EMPLOYED PART TIME?                         NO              YES
     HOW MANY PART TIME HOURS PER WEEK? _________________________________________                      7.   I AUTHORIZE THE RELEASE OF ANY INFORMATION OR RECORDS REQUESTED IN RESPECT
                                                                                                            OF THIS CLAIM TO THE INSURER/PLAN ADMINISTRATOR AND CERTIFY THAT THE INFORMA-
2. ARE ANY DENTAL BENEFITS OR SERVICES PROVIDED UNDER ANY OTHER GROUP                                       TION GIVEN IS TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
     INSURANCE OR DENTAL PLAN, W.C.B. OR GOV'T PLAN?                    NO               YES
                                                                                                                                                      DATE ________________________________
     POLICY NO. ____________________ SPOUSE DATE OF BIRTH ___________________________                                                                          DAY      MONTH        YEAR
                                                                   DAY           MONTH         YEAR
                                                                                                       __________________________________________________
     NAME OF OTHER INSURING AGENCY OR PLAN _______________________________________                     SIGNATURE OF EMPLOYEE/PLAN MEMBER/SUBSCRIBER

 PART 4 - POLICY HOLDER/EMPLOYER
                                             DAY         MONTH   YEAR
                                                                           4. CONTRACT HOLDER
1. DATE COVERAGE COMMENCED                                                                                               DATE               _____________________________________________
                                                                                                                                                       AUTHORIZED SIGNATURE
2. DATE DEPENDENT COVERED

3. DATE TERMINATED                                                                                                                          _____________________________________________
                                                                                                                 DAY    MONTH     YEAR
                                                                                                                                                         (POSITION OR TITLE)
                                                                  ALL INFORMATION RECORDED ON THIS FORM IS CONFIDENTIAL                                                          520(1999/01/12)

				
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