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PHYSICIAN’S STATEMENT

Physician:

_____________________________________

Address:

_____________________________________________________

Tel: (______) __________________

Name of Hospital / Clinic : _____________________________________________________ Nature of Injury: ________________________________________________________________ Address: Date of First Attendance: ___________________________________________________ __________ _________ __________ / /

__________________________________________________________________________________

Claimant will be totally disabled:

From:

To:

_____________

_____________________________________________________________________

___________________

___________________

Is the injury permanent and irrecoverable? No

  • Yes

Give details of injury (degree) :

_____________________________________________________________________________________________________________

_________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Prognosis for recovery : _________________________

Did any disease or previous injury contribute to the current injury?

  • No

  • Yes (describe): ______________________________________________

______________________________________________________________________________________________________________________________________________

Was claimant hospitalized?

  • No

  • Yes (give hospital name, address and date admitted): ________________________________________________

_________________________________________________________________________________________

_____________________________________________________

Names and addresses of other physicians or surgeons, if any, who attended claimant:

________________________________________________________

____________________________________________________________________________

__________________________________________________________________

I certify that the above information is correct to the best of my knowledge, Signed: ____________________________________________________________________

Date:

_________________________________________________________

DENTIST’S STATEMENT

Limits of coverage: $1,250 per tooth, $2,500 per accident Treatment must be completed within 52 weeks of accident

P LAST NAME A

GIVEN NAME

UNIQUE NO. SPEC. PATIENT’S OFFICIAL ACCOUNT NO.

D E

I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM DIRECTLY TO THE NAMED DENTIST AND AUTHORIZE PAYMENT DIRECTLY TO HIM/HER

T

___________________________________

I ADDRESS

APT.

N T

E

I

N

T

___________________________________

CITY

PROV.

POSTAL CODE

S

T

PHONE NO.

SIGNATURE OF SUBSCRIBER

FOR DENTIST’S USE ONLY – FOR

ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES, OR SPECIAL CONSIDERATION.

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 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 CONTAINED IN THIS CLAIM FORM TO MY INSURING COMPANY/PLAN ADMINISTRATOR.

DUPLICATE FORM

SIGNATURE OF (PATIENT/GUARDIAN)

DATE OF SERVICE

INITIAL TOOTH

TOOTH

DENTIST’S

LAB

TOTAL

DAY / MO. / YR.

PROCEDURE

CODE

SURFACE

FEE

CHARGE

CHARGE

OFFICE VERIFICATION

THIS IS AN ACCURATE STATEMENT OF SERVICES PERFORMED AND THE TOTAL FEE DUE AND PAYABLE & OE.

TOTAL FEE SUBMITTED

NOTE: All benefits subject to insurer payor status, provisions of the policy, Hockey Canada sanctioned events.

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