Transcription of Dental Claim Form - Saskatchewan
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Dental Claim Form - Saskatchewan
Page 1 of 2 DENT-25273-E-11-14 (G6108-E) 3 | Spouse and children covered by this Claim complete this section if Claim is for spouse or child 4 | Co-ordination of benefits complete this section if your spouse and/or children has coverage under any other Dental plan or contractApproved by the Canadian Dental AssociationDental Claim form 1 | To be completed by Dentist Last Name Given Name Unique Number Spec. Patient s Office Account No. Address Apt. City Prov. Postal Code Phone No.:For Dentist s 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 planspecial 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.
Page 1 of 2 DENT-25273-E-11-14 (G6108-E) 3 | Spouse and children covered by this claim – complete this section if claim is for spouse or child 4 | Co-ordination of benefits – complete this section if your spouse and/or children has coverage under any other dental …
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