Dental Authorization / X-Ray Submission Form

 Dental X-Rays can be submitted to the following carriers:

  • Green Shield Canada
  • SSQ Financial Group
  • RBC Insurance

 

* indicates a mandatory field
Provider Information
Name: *
UIN #: *
Street Address 1:  
Street Address 2:  
City:  
Province:  
Postal Code:  
Telephone Number: * () -
Email Address:  
Confirm Email Address:  
Patient Information
Carrier: *
Plan Member ID #: * -
Given Name: *
Last Name: *
Date of Birth: * [yyyy mm dd]
Street Address 1:  
Street Address 2:  
City:  
Province:  
Postal Code:  
Predetermination Information
Tooth # Procedure Code* $* Lab $
Comments  (limit 450 characters)  0 *
Restorations  (Only required if submitting for restorations)
Tooth # Surfaces (e.g. MOD)
Missing Teeth  - Required for any bridge/implant submission. List only those teeth that have not been replaced with a fixed prosthesis.
Upper Arch:
Lower Arch:
Existing Bridges - Abutment = A / Pontic = P/ Implants = I
18 17 16 15 14 13 12 11
21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41
31 32 33 34 35 36 37 38
Endodontically Treated Teeth
File Attachments * (Expertise statements, x-rays and/or photos may be attached.)
1.
2.
3.
4.
5.
This is an approximation only.
Final laboratory charges will be included on claim form when treatment is completed.

By submitting this form, I acknowledge that the Plan Member has given written authorization to submit personal information to the carrier necessary for claims adjudication, and for the carrier to exchange information with other parties as required and only when the information is needed to administer this benefit claim and/or to confirm the accuracy of this information.

I agree that the information provided is complete and accurate, to the best of my knowledge.


Submit
Cancel
 
© 2017 providerConnect™ Skip Navigation Links
LEGAL
PRIVACY
SECURITY
TECHNICAL SUPPORT