Standard Dental Claim Form - Groupsource
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1STANDARD DENTAL
GroupSource
Suite 200, 5970 Centre Street SE
CLAIM FORM
Calgary, AB T2H 0C1
Phone: (403) 228-1644
Toll Free: 1-866-862-5246
Fax: (403) 228-1775
PART 1 - DENTIST
Unique No.
Spec
Patients Office Account No.
I hereby assign my benefits payable from
P
this claim to the named dentist and authorize
Last Name
Given Name
A
D
payment directly to him / her.
E
T
N
I
Address
Apt.
T
E
I
Phone No.
N
S
Signature of Employee
City
Prov.
Postal Code
T
T
For dentist 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
Pre-treatment x-rays are required for estimates and claims involving major dental work
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 is for services
rendered.
Duplicate Form
Signature of Patient (parent / guardian)
INTL.
INSTRUCTIONS FOR CLAIMS
DATE OF
TOOTH
LABORATORY
PROCEDURE CODE
TOOTH
DENTIST’S FEE
TOTAL CHARGES
SUBMISSIONS
SERVICE
SURFACES
CHARGE
CODE
yyyy
mm
dd
All parts of this form must be completed in
full. If information is missing, the form may
be returned to you.
1. Have the attending dentist complete Part 1
2. You complete Parts 2, 3 and 4 below
FOR CARRIER USE
TOTAL FEE
This is an accurate statement of services performed and the total fee due
and payable. E & OE.
Office Verification / Dentist’s Signature
PART 2 - PATIENT INFORMATION
1. Relationship of patient to Employee
Yes
No
4. Is any of the above work for Orthodontic purposes?
Date of Birth:
yyyy
mm
dd
5. (a) If treatment is due to an accident, indicate the date:
yyyy
mm
dd
2. If claim is for dependent child, is that child:
Yes
No
(b) Is a claim being made for Workers’ Compensation Benefits?
Handicapped?
Yes
No
A Full Time Student?
Yes
No
6. If the treatment involves the placement of a bridge, denture or crown, is this initial placement?
Name of School
No. of hours per week
Yes
No
Upper
Lower
Yes
No
3. Are dental benefits or services provided under any other insurance plan?
If yes, provide:
No
Yes
If “No” provide the previous placement date: yyyy
mm
dd
Policy Number
Name of Insurer
If initial denture or bridge, indicate dates teeth were extracted: yyyy
mm
dd
Spouse’s Name
7. Do you want any unpaid balance from this claim reimbursed from your Health Spending Account
(if applicable)?
Yes
No
Spouse’s Date of Birth
mm
dd
PART 3 - EMPLOYEE INFORMATION
Policy Number
Employer Name
Employee Identification Number
Gender
Last Name
Given Name
Name Commonly Used
Male
Female
Apt. / House #
Street Address
Date of Birth
yyyy / mm / dd
City
Province
Postal Code
Daytime Tel. No. / Evening Tel. No.
PART 4 - AUTHORIZATION AND DECLARATION
I certify that the information contained herein is true, complete and accurate and that each of the listed expenses was purchased and/or incurred in connection with dental treatment of the above-named individuals. I
acknowledge that the submission of false or incomplete information may result in the delay or denial of this claim. I authorize any physician, dentist or any health care provider and/or facility, any insurance company,
benefit service provider and any other person or organization having any medical or other relevant personal information regarding me or my spouse and/or dependant to release to and exchange with the insurer, the
group plan administrator or their representatives and/or agents any and all information necessary to investigate and confirm the accuracy and validity of this claim, determine eligibility for benefits and/or administer the
claim and group benefit plan. I confirm that I am authorized to act on behalf of my spouse and/or dependents for such purposes. Any copy of this Authorization and Declaration shall be as valid as the original.
Original Employee Signature is required on all claim forms
Sign only if mandated by Administrative Services Only (ASO) arrangement:
Employee Signature
Date
Employer Signature
Date
07-14GroupSource.DTL.CLAIM
GroupSource is committed to protecting the confidentiality, accuracy and security of the personal information it collects and uses in the course of conducting business.
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