Government of Ontario: Ministry of Health and Long-Term Care Homes for Special Care

Dental Claim

Submit this form to the local HSC office. This form may also be used to submit treatment estimates.

Dentist

Name

HSC client's last name

Given name

Address

Name of Home for Special Care (HSC)

Address of HSC

City

Province

Postal code

Telephone

For HSC use only

Licence no.

Client Plan no.

Each submission must contain fee guide code, verbal descriptions, fees, and distrubtion of missing teeth.

Date of service (dd/mm/yyyy)

Int tooth code

Procedure code

Tooth surface

Abbreviated verbal description

Fee requested $

Fee approved $/

Circle patient's missing teeth

Date of service (dd/mm/yyyy)

Int tooth code

Procedure code

Tooth surface

Abbreviated verbal description

Fee requested $

Fee approved $

Date of service (dd/mm/yyyy)

Int tooth code

Procedure code

Tooth surface

Abbreviated verbal description

Fee requested $

Fee approved $

For dentist's use

Additional information, diagnosis, procedures, complicatoins, or alternate treatment proposal

Total dentist's free

Total lab fee

Total fee

This is an accurate statement of services performed and fees charged. E & OE

Dentist signature

Date

Dentist consultant's signature

Date

Policy:

Fees will be approved according to the previous year’s ODA Suggested Fee Guide for General Practitioners and Denturist Association’s Suggested Fees.

A maximum of $1500.00 per client may be approved each calender year. Crowns, bridges, and root canal treatment will be paid at 75% of the previous years fees.

Dentures will be approved no more than once every two(2) years. Scaling will be approved to amaximum of 4 minutes per tooth, every 6 months.

3653-41 (01/07)