Manufacturers Life Fillable Forms
Dental Claim PART 1 - DENTIST P A T ADDRESS I E N CITY T LAST NAME GIVEN NAME APT. UNIQUE NO. SPEC. PATIENT'S OFFICE ACCT. NO. PROV. POSTAL CODE D E N T I S PHONE NO. T I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM TO THE NAMED DENTIST AND AUTHORIZE PAYMENT DIRECTLY TO HIM/HER. FOR DENTIST'S USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES, OR SPECIAL CONSIDERATION. SIGNATURE OF PLAN MEMBER/EMPLOYEE I UNDERSTAND THAT THE FEES LISTED IN THIS CLAIM MAY NOT BE COVERED BY OR MAY EXCEED MY PLAN BENEFITS MoreIF YES, GIVE DATE AND DETAILS Less
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