Dental Claim Form - The Co

Group benefits
Dental Claim Form
Dental
Health Spending Account
Claim If your plan provides a Health Spending Account, should any unpaid balance of this claim be reimbursed
Yes No
under your account? Treatment Plan
Instructions
DIRECT DEPOSIT AND ELECTRONIC CLAIM STATEMENT
Please mail your completed claim form and receipts to:
Co-operators Life Insurance Company
Dental Claims
1920 College Avenue
Regina, SK S4P 1C4
You will receive your claim payments faster with direct deposit and enjoy the convenience of seeing your
claim statements online.
Sign up for direct deposit and electronic claim statements by calling our Client Service Centre at
1-800-667-8164 or signing in to Benefits NowTM.
Part 1 - Dentist
Last Name
P
A
T
I
E
N
T
Given Name
P
R
O
V
I
D
E
R
Address
City
Province
Postal Code
Patient
ID Number
Specialty
Unique Number
I hereby assign my benefits payable
from this claim to the named dentist and
authorize payment directly to him/her.
____________________________________
Plan Member Signature
Telephone Number:
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.
Duplicate Form
I acknowledge 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.
Provider’s Use Only - For additional information, diagnosis, procedures or special considerations.
_____________________________________________
Patient (Parent/Guardian) Signature
Yes Was this emergency treatment? Attachments: Radiographs (large/small) Date of Service
(MMM/DD/YYYY)
No If Yes, please provide additional details.
Models Photographs Procedure Code
Office Verification: Written Diagnostic Report
Tooth Code
Tooth Surfaces
______________________________________________
Dentist/Denturist Signature
Professional Fee
Laboratory Charge
This is an accurate statement of services performed and the total fee due and payable, E & OE.
Total Charges
Total Fee Submitted $
Part 2 - Plan member Information
Group _________________ Account _ __________________ Certificate _______________________ Plan Sponsor/Employer_________________________________
Plan Member _ ____________________________________ ______ ________________________________________ Date of Birth ___________________________
First Name
Initial
Last Name
MMM/DD/YYYY
Address _______________________________________________ __________________________________ _________________________ ____________________
Street
City
Province
Postal Code
Part 3 - Patient Information
1. Relationship to Plan Member ______________________________________________________________________________ Date of Birth _ ___________________
MMM/DD/YYYY
If child, indicate Student Handicapped
If a student, please ensure the annual Student Eligibility Form has been completed and submitted to our office by August 15 of each year.
2. Co-ordination of Benefits
If this expense has been considered by another carrier, you must attach the original explanation of benefits from that plan along with copies of the receipts.
Are you or your dependents covered by another plan? Yes No If yes, provide the following:
Spouse Date of Birth _______ ___________________ Insurance Company Name/Source:_______________________________ Policy:_____________________
Day
Month
If your spouse’s benefit plan is with Co-operators Life Insurance Company, do you want us to process the claim through both benefit plans? Yes No
Spouse’s Policy __________________________________________________________________________ Certificate ____________________________________
3. Is any treatment related to an accident? Yes No
If yes, a Supplementary Dental Accident Report form will be sent directly to your dental office for completion.
4. If denture, crown or bridge, is this initial placement? Yes No
If no, give date of prior placement and reason _ ______________________________________________________________________________________________
5. Is any treatment related to orthodontics? LC231 (09/11)
Yes No
Co-operators Life Insurance Company
1920 College Avenue Regina SK S4P 1C4
(see reverse)
PG 1 of 2
Part 4 - Plan Sponsor Authorization (only if required)
Employment Date _____________________ Employee’s/Member’s Effective Date _______________________ Dependent’s Effective Date ______________________
MMM/DD/YYYY
MMM/DD/YYYY
Termination Date (if applicable) _____________________ Retirement Date ______________________ Status MMM/DD/YYYY
MMM/DD/YYYY
MMM/DD/YYYY
Single Couple Family
Signature of Authorized Official_____________________________________________________________________________ Date _ ____________________________
MMM/DD/YYYY
Part 5 - PRivacy and Authorization
Co-operators Life Insurance Company Privacy Statement
Co-operators Life Insurance Company is committed to protecting the privacy, confidentiality, accuracy and security
of the personal information that it collects, uses, retains and discloses in the course of conducting business.
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
medical 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 dependent to release to and exchange with Co-operators Life
Insurance Company, 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 shall be as valid as the original.
In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning this claim, I acknowledge and agree that Co-operators Life Insurance Company
may investigate and that information about me, my spouse and/or dependents pertaining to this claim may be used and disclosed to any relevant organization
including regulatory bodies, government organizations, medical suppliers, and other insurers, and where applicable my Plan Sponsor, for the purpose of
investigation and prevention of fraud and/or plan abuse.
If Co-operators Life Insurance Company pays me an amount that exceeds the benefit(s) to which I am entitled under my plan (the Overpayment Amount), then I
acknowledge and agree that: (a) I am indebted to Co-operators Life Insurance Company for the Overpayment amount (b) Co-operators Life Insurance Company
has the right to recover the Overpayment Amount through any means available by law, and (c) Co-operators Life Insurance Company will offset any benefits payable
to me by the Overpayment Amount until Co-operators Life Insurance Company has recovered the Overpayment Amount in full.
Plan Member Signature _______________________________________________________________________________ Date __________________________________
LC231 (09/11)
MMM/DD/YYYY
Co-operators Life Insurance Company
1920 College Avenue Regina SK S4P 1C4
PG 2 of 2