Canada GSC Dental Accident Report Form 2015 free printable template
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P.O. BOX 1608 WINDSOR, ONTARIO N9A 7G1 1-800-265-5615 ext. 6885 DENTAL ACCIDENT REPORT FORM PATIENT Names: GREEN SHIELD I.D. NO.: ADDRESS: RELATIONSHIP TO PLAN MEMBER: CITY/PROV/ POSTAL CODE: EMAIL
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How to fill out Canada GSC Dental Accident Report Form
How to fill out Canada GSC Dental Accident Report Form
01
Obtain the Canada GSC Dental Accident Report Form from the appropriate source, such as your dentist's office or the Great-West Life website.
02
Fill in the patient's personal information, including name, address, date of birth, and insurance policy number.
03
Provide details about the accident, including the date, time, and location of the incident.
04
Describe the nature of the dental injury thoroughly, detailing what happened and how the injury occurred.
05
Include any relevant medical information, such as previous dental issues or treatments received.
06
Have the attending dentist complete their section of the form, providing their name, license number, and any necessary comments.
07
Sign and date the form to verify the accuracy of the information provided.
08
Submit the completed form to the relevant insurance company or dental plan administrator as directed.
Who needs Canada GSC Dental Accident Report Form?
01
The Canada GSC Dental Accident Report Form is required for individuals who have sustained a dental injury due to an accident and wish to make a claim for dental treatment under their insurance plan.
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What is Canada GSC Dental Accident Report Form?
The Canada GSC Dental Accident Report Form is a document used to report dental accidents or injuries for claims processing related to dental insurance.
Who is required to file Canada GSC Dental Accident Report Form?
The form is required to be filed by individuals who have experienced a dental accident and wish to claim insurance benefits for related dental treatment.
How to fill out Canada GSC Dental Accident Report Form?
To fill out the form, provide personal information, details about the accident, the dental services received, and any relevant insurance policy information.
What is the purpose of Canada GSC Dental Accident Report Form?
The purpose of the form is to document the details of a dental accident to facilitate the claims process for insured dental treatments.
What information must be reported on Canada GSC Dental Accident Report Form?
The information that must be reported includes the date and location of the accident, a description of the injury, treatment received, and the claimant's insurance information.
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