Dental Claim Form

Approved by the Canadian Dental Association

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1 To be completed by Dentist
P Last Name Given Name Unique Number Spec. Patients Office Account No. I hereby assign my benefits payable
A from this claim to the named dentist
D and authorize payment directly to
T Address Apt.
E him/her.
I N
E T
City Prov. Postal Code I
N
S
T T Phone No.: Signature of Subscriber
For Dentists Use Only - For additional information, diagnosis, procedures, or I understand that the fees listed in this claim may not be covered by or may exceed my plan
special consideration. 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 has been charged to me for
services rendered. I authorize release of the information in this claim form to my insuring
company / plan administrator.

Duplicate Form Signature of Student Mandatory

Office Verification/Dentists Signature
Intl
Date of Service
Day Month Year
Procedure
Code
Tooth
Code
Tooth
Surfaces
Dentists
Fee
Laboratory
Charge Total Charges For Plan Administrator Use Only

This is an accurate statement of services

performed and the total fee due and TOTAL FEE SUBMITTED
payable E & OE

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2 To be completed by Insured Student be sure to fully complete this section
Contract number Student ID number Group name Preferred language of correspondence
56003 SSU Dental Plan English French
I I I I I I I I
Your last name First name Male Date of birth (yyyy-mm-dd) Daytime phone number
Female
Your address (street number and name) Apartment or suite City Province Postal code

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3 Spouse and children covered by this claim complete this section if claim is for spouse or child
Spouses last name First name Date of birth (yyyy-mm-dd) Male
Female
Childs name Relationship to you Date of birth (yyyy-mm-dd) Complete for overage dependents (refer to benefit information
Son Daughter for age limits)
Disabled Full-time student

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4 Co-ordination of benefits complete this section if your spouse and/or children has coverage under any other dental plan or contract
Is your spouse or are your children covered for any of these expenses under any other dental plan or contract? No Yes
If yes,: You must submit a claim for your spouse to his/her plan first.
You must submit a claim for your child first under the plan of the parent with the earliest birthday (month and day) in the
calendar year.
If your spouses plan is also with us, complete the following:
Contract number Member ID number Spouses date of birth (yyyy-mm-dd) Do you want us to co-ordinate benefits (process both claims)?
No Yes

If yes, spouses signature Date (yyyy-mm-dd)

X

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5 Details of claim
If the cost of your treatment will exceed the pre-determination limit in your benefit plan, you should send an estimate to Sun Life
Assurance Company of Canada. To determine if you will be reimbursed for the treatment, have your dentist complete a Pre-Treatment
Form (available from your dentist).
Are any expenses the result of an accident? No Yes If yes, complete the following:
When did the accident occur? (yyyy-mm-dd) Where did the accident occur? How did the accident occur?
Work Home Other

Are any expenses the result of a condition covered by a workers compensation program? No Yes

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6 Authorization and signature you must complete this section
I certify that all goods and services being claimed have been received by me and/or my spouse or dependents, if applicable.
I certify that the information in this form is true and complete and does not contain a claim for any expense previously paid
for by this or any other plan.
If this claim is being made on behalf of my spouse and/or dependents, I am authorized to disclose information about them,
for the purposes of underwriting, administration and adjudicating claims. I confirm that my spouse and/or dependents, if
any, also authorize Sun Life Assurance Company of Canada (Sun Life) to disclose information about their claims to me, for
the purposes of assessing and paying a benefit, if any, and managing my group benefits plan.
I authorize Sun Life and its reinsurers to collect, use and disclose information about me, and if applicable, my spouse
and/or dependents needed for underwriting, administration and adjudicating claims under this Plan to any other
organization who has relevant information pertaining to this claim including health professionals, institutions, investigative
agencies and insurers. I also understand that information pertaining to this claim may be reviewed in the event this Plan
is audited.
In the event there is suspicion and/or evidence of fraud and/or Plan abuse concerning this claim, I acknowledge and agree
that Sun Life 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 there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable to
me under my benefit plan(s), and the collection, use and disclosure of information about this claim to other persons or
organizations, including credit agencies and, where applicable, my Plan Sponsor for that purpose.
I authorize Sun Life Assurance Company of Canada to disclose the information pertaining to this claim to Studentcare for
benefits administration.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect
for the continued administration of this Plan.
Any reference to Sun Life Assurance Company of Canada or the Plan Sponsor includes their respective agents and service providers.
Signature of Insured Student (Mandatory) Date (yyyy-mm-dd)
X
Respecting your privacy
Your privacy is important to us. We may leverage our strengths in our worldwide operations and in our negotiated relationships with
third-party providers to help us service some of our customers. In some instances our employees, service providers, agents, reinsurers and
any of their service providers, may be located in jurisdictions outside Canada, and your personal information may be subject to the laws of
those foreign jurisdictions.
To find out about our Privacy Policy, visit our website at www.sunlife.ca, or to obtain information about our privacy practices, send a written
request by email to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5.
Important:
All claims must be received by Sun Life Assurance Company of Canada no later than 90 days after the end of the policy year in which the
claims were incurred or 90 days after the end of your coverage, whichever is sooner. For more information, refer to your booklet or get in
touch with Studentcare. If you are under a treatment program which will involve a series of treatments for an extended period you should
file a claim periodically and indicate on the claim form that it is part of an on-going treatment plan.

For details specific to Mail your completed form to:

your Plan, visit
www.studentcare.ca
Sun Life Assurance Company of Canada
PO Box 2010 Stn Waterloo
Waterloo ON N2J 0A6
Please retain a copy of your claim form and receipts for your records.

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