Fillable Printable Dental Treatment Plan - Canada
Fillable Printable Dental Treatment Plan - Canada
Dental Treatment Plan - Canada
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I hereby assign my benets payable
from this claim to the named provider
and authorize payment directly to
him/her.
Unique Number Specialty Last Name First Name
Signature of member
Address
City Province Postal Code
Telephone
Number:
I understand that the fees listed in this claim may not be covered by or may
exceed my plan benets. I understand that I am nancially responsible to the
provider 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 communication of
information related to the coverage of services described in this form to the
named dental provider.
PROVIDER'S USE ONLY - For additional information, diagnosis,
procedures or special considerations.
ATTACHMENTS Radiographs (large/small) Models Photographs Written Diagnostic Report
Duplicate Form
Signature of Patient
(Parent / Guardian)
OFFICE VERIFICATION: Dentist / Denturist Signature:
Was this emergency treatment? No Yes - If yes, please provide additional details.
PART 1 - DENTAL SERVICE PROVIDER
ABC 20041 2013/02
10009-108 Street NW, Edmonton, Alberta T5J 3C5
DATE OF SERVICE
PROCEDURE
CODE
TOOTH
SURFACES
LABORATORY
CHARGE
PROFESSIONAL
FEE
TOOTH
CODE
1
2
3
4
5
6
7
8
9
This is an accurate statement of services performed and the total fee due and payable, E. & O.E.
Total Fee Submitted
>
PART 2 - MEMBER INFORMATION
ALL INFORMATION RECORDED ON THIS FORM IS CONFIDENTIAL
®
The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross
Plans, an association of independent Blue Cross plans. Licensed to ABC Benets Corporation for
use in operating the Alberta Blue Cross Plan.
MMYYYY DD
DENTAL TREATMENT PLAN
CLAIM Verication No.:
Patient
ID Number
-
Referred by: Name
Name of Employer
Blue Cross Group and ID Number
Member's Name
If service claimed is a Denture, Bridge or Crown,
is this an initial placement?
No - Please indicate type and age of prosthesis being replaced,
the reason for replacement and teeth missing.
Yes - If partial denture or bridge, please indicate which teeth are
being replaced & date(s) they were extracted.
Was treatment the result of an accident?
No Yes -
If yes, please complete the reverse side of this page.
Patient's
Date of Birth
YYYY DDMM
Patient's Relationship to Member:
Self Spouse Son Daughter Other (Specify):
Do you have any additional Blue Cross Plans that
would provide dental benets?
No Yes - If yes, please complete the following:
Do you have any other coverage with another carrier
that would provide dental benets?
No Yes - If yes, please complete the following:
Insuring Company Name or Name of Employer
YYYY MM DD
Date of Birth
YYYY MM DD
Date of Birth
Name of Insured
Cancellation Date
YYYY MM DD
If Other Plan is no longer in effect
please state:
Policy Identication Numbers
Cancellation Date
YYYY MM DD
If Other Plan is no longer in effect
please state:
PART 3 - PATIENT INFORMATION (Refer to ID card)
Group Class
Given Name
Telephone Number(s) During Business Hours
-
Member ID Number
Member's Signature:
I hereby declare this claim is for an eligible dependent as dened under my dental benet
coverage and all information is correct and complete to the best of my knowledge.
I authorize the following to exchange information needed to determine my or my dependent's
eligibility for coverage, to verify, assess and pay claims, and to administer the benet plan:
Alberta Blue Cross, health care professionals/practitioners/institutions, health benets
providers or insurance companies.
Last Name
Member's Date of Birth
YYYY DDMM
NOTE: If the Member's address has changed since the last claim was made, please contact your benet plan administrator
with the new address.
ACCIDENT REPORT
PRACTITIONER'S REPORT OF INJURY (Please indicate tooth codes, extent of damage and forward appropriate radiographs.)
MEMBER'S REPORT OF ACCIDENT
DATE YYYY MM DD
ACCIDENT
OCCURRED
LOCATION OF ACCIDENT
PLEASE STATE THE CIRCUMSTANCES LEADING TO AND MATTERS CAUSING THE ACCIDENT
Are any services being claimed through the Workers' Compensation Board?
No Yes - If yes please provide details:
DATE MEMBER'S SIGNATURE
If injury is the result of a Motor Vehicle Accident or an Assault, please provide the following:
a) Copy of police report
b) Full name, address and telephone number of any witness(s) to the accident
Acknowledgement and consent to release this information is provided on the front of this form.
