Get Dental Report Form

Filling out the Dental Report Form online is an essential process for ensuring proper documentation and claim processing. This guide will provide you with step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to successfully complete the Dental Report Form

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the patient section, including the patient's name, Green Shield ID number, address, and relationship to the plan member. Ensure that all contact information is current and accurate.
3. Complete the mandatory declaration section. Indicate whether there is any other group insurance coverage. If applicable, provide the insurance company name and Green Shield Canada ID number.
4. Specify if the treatment is required due to a motor vehicle accident or a work-related injury by selecting 'Yes' or 'No' for each question.
5. Enter the date and location of the accident, including the province, state, or country where it occurred.
6. Briefly describe how the accident occurred in the provided space. Keep the description concise yet informative.
7. Sign the form where indicated to authorize the release of any required information and certify the accuracy of the details provided.
8. If applicable, complete the dentist section by providing the dentist's name, unique number, address, and phone number, and ensure the dentist signs the form.
9. Describe the damage, including specific tooth numbers, to give clarity regarding the injuries incurred.
10. Upload any necessary documents such as predetermined claims or incurred claims, and ensure that x-rays are attached if required.
11. After filling out the form, you can save changes, download, print, or share the completed form.

Complete the Dental Report Form online today and ensure your claims are processed smoothly.