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P. O. BOX 1614 Windsor, Ontario N9A 0B9
Attn: Dental Department or Customer Service Centre 1-855-264-2174
PART 1 - PROVIDER
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Patient Last Name Given Name
Address Apt.
City Prov. Postal Code
For provider's use only - for additional information, diagnosis,
procedures, or special consideration.
Duplicate Form
DENTAL CLAIM FORM
Unique No. Spec Patient's Office Account No.
I hereby assign my benefits payable from this
claim to the named provider and authorized
payment directly to him/her
P
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V
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Signature of Plan Member
Phone No
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 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 the communication of information related to the coverage of services described in this form to the named
provider.
Signature of Patient (Parent/Guardian)
Office Verification
Allowed Amount Total Charges
Laboratory Charges
Provider's Fee
Tooth Surfaces Int'l Tooth Code
Procedure Code
Date of Service
DAY MO YR.
This is an accurate statement of services performed and
the total fee due and payable, E & OE.
Code
TOTAL FEE SUBMITTED
INSTRUCTIONS FOR CLAIM SUBMISSION:
Please carefully fill in all pertinent areas and sign the completed form. (Refer to RBC Life Identification Card for correct patient information). Incomplete or incorrect claim forms
will be returned or rejected and will result in a delay in reimbursment.
All claims must be submitted within 12 months of the date of service (unless otherwise
stated in your benefit plan documentation).
PART 2 - EMPLOYEE/PLAN MEMBER
Plan Member's Date of Birth
Yr Mo Day
Plan Member's Identification NumberPlan Member's Name (Please Print)
-00
Given Names Last Name
PART 3 - PATIENT INFORMATION
Patient's Date of Birth
Yr Mo Day
Patient's Identification NumberPatient's Name (Please print)
--
Given Names Last Name
3. Is any treatment required as the result of an accident? if Yes, give
date and details separately.
1. Patient: Relationship to Plan Member
Yes No
4. If denture, crown or bridge, is this initial placement? Give date of
prior placement and reason for replacement.
Yes No
HandicappedStudentIf child, indicate:
5. Is any treatment required for orthodontic purposes? If student, indicate school
Yes No
I authorize the release of any information or records required
in respect of this claim to insurer/plan administrator and
certify that the information given is true, correct and
complete to the best of my knowledge.
Yes No
2. Are any dental benefits or services provided under any other group insurance
or dental plan, W.S.I.B. or Government plan?
If Yes, Policy No.
Spouse Date of Birth
Date
Name of other insuring Agency or Plan
Ye ar MonthDay
Signature of Plan Member
All information recorded on this form is confidential.
I am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this information may be seen by the cardholder.
By signing this claim form and/or submitting actual receipts, I agree that the information provided is complete and accurate. I understand that the information provided by me to RBC Life about myself and my dependents, will
be used by RBC Life for claims adjudication and any other services necessary in the administration of our benefits which may include the exchange of information with other parties to administer this benefit claim.
I further authorize RBC Life to obtain and exchange information with other parties, such as health practitioners or insurers, in order to confirm the accuracy of the submitted claim(s) information. In the event of suspected
fraudulent activity pertaining to claims submitted on behalf of myself and/or my dependents, I acknowledge and agree to the disclosure of this information to relevant parties, such as the Plan Sponsor, regulatory and law enforcement
agencies.
DE (Rev. 2018-12)
click to sign
signature
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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