Fillable CLAIM FOR DENTAL CARE EXPENSES A DENTIST INFORMATION (Desjardins Insurace)

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CLAIM FOR DENTAL CARE EXPENSES A DENTIST INFORMATION (Desjardins Insurace)

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
  
   
A DENTIST INFORMATION
YYYY MM DD
  
  
IMPORTANT: If the claim is for dental treatment due to an accident, a crown, veneer applicaon, inlay or denture, please refer to secons J and K.
If the treatment requires more than one session, the date of treatment must be the date on which the treatment terminates or the inseron date.


THIS
IS AN ACCURATE STATEMENT OF SERVICES PERFORMED
AND
FEES CHARGED.

 Date













YY
MM
DD


Group Insurance - Health Claims
CLAIM FOR DENTAL CARE EXPENSES
B
CLAIM INFORMATION


Signature of member: Date:
C
ASSIGNMENT OF BENEFITS
D
MEMBER INFORMATION

Sex
M
YYYY MM DD
  
 
   



  
YYYY MM DD
YYYY MM DD
E
COORDINATION OF BENEFITS


  
 
 
 


M 
 
   
YYYY MM DD
YYYY MM DD
YYYY MM DD

Ineligible expenses 
Spouse's family coverage 





F HEALTH SPENDING ACCOUNT 



  



 

G DIRECT DEPOSIT SERVICE 


   






                      

Signature of the member: Date:
I DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION








H PERSONAL INFORMATION MANAGEMENT
Please sign secon I and send to: Desjardins Insurance, C. P. 3950, Lévis (Québec) G6V 8C6
J
DENTAL TREATMENT DUE TO AN ACCIDENT
• For crown, veneer or inlay/onlay:
• For xed bridge:

• For denture:
Please include a copy of the commercial lab bill with your claim.
K CLAIM FOR A CROWN, VENEER, INLAY/ONLAY, FIXED BRIDGE OR DENTURE
4
4
 

YYYY MM DD
  

TO BE COMPLETED BY THE DENTIST
TO BE COMPLETED BY THE MEMBER
If the claim is the result of a work injury or a motor vehicule accident, please note that the claim must rst be submied to your provincial automobile insurance
(if applicable in your province) or occupaonal health and safety plan before being forwarded to your insurer.
Preoperave X-rays are required for the study of dental treatment due to an accident. They will be returned to the aending denst as soon as possible.
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CLAIM FOR DENTAL CARE EXPENSES A DENTIST INFORMATION (Desjardins Insurace)

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Completed 9 February 2021

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