Public Employees Benefits Agency 110 - … Public service group insurance benefit plans, Claim Form for Public Service Dental Care Plan (PSDCP), Public Service Dental Care Plan (PSDCP) - Authorization for Claims Submission and Redirection of Payment, Claim Form (PDF Document - 54 KB - Sun Life Financial), Pensioners’ Dental Services Plan (PDSP) Authorization for Claims Submission and Re-direction of Payment Form, PSMIP Claim Form for Long-Term Disability Benefit (Forms number TBS 5945 & 5946), PSMIP Claim Form for Accidental Dismemberment Benefit (Forms number TBS 5954 & 5955), PSMIP Claim Form for Death Benefit (Forms number TBS 5948 & 5949), Long-term Disability Insurance – PSMIP (Part-time Employee Only), PSMIP (Change of Name or of Beneficiaries), PSMIP – Members Entitled to Government-Paid Coverage, Post-retirement Life Insurance Plan (Change of Name/Change of Beneficiary), Application form for active and retired members, Veterans Affairs Canada Application and Amendments forms, Attending Physician’s Questionnaire (490L-P-12500-GEN-E, 490L-P-12500-MHC-E, or 490L-P-12500-MSK-E), Employer’s Statement (Immediate Supervisor or Manager)(4841-E), Employer’s Statement (Compensation Advisor)(4811-E). Public Service Health Care Plan Claim Form (PDF) Sun Life Financial (Member sign-in) Dental care (dependants) Public Service Dental Care Plan; Claim form (PDF) Date Modified: 2020-10-14. The Public Service Health Care Plan forms are found on PSHCP.ca. Service Centre Contact Information. The voluntary PDSP was established by the Government of Canada in 2001. The PSHCP Relief Provision application form is found on the Public Services and Procurement Canada website. For More Information… Please review the ARTA Membership Eligibility. Note: If you are about to retire, you can obtain the Pensioners’ Dental Services Plan (PDSP) form (used to enrol, amend or terminate PDSP coverage) from the Government of Canada Pension Centre. standard dental claim form. ADA Dental Claim Form The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. Here you can access forms for the Public Service Management Insurance Plan (PSMIP). Plan member Plan sponsor (PDF, 2 pages, 743.53 KB) Life. card . You can receive your claim reimbursement faster by signing up for Direct Deposit through the Sun Life Member Services website at www.sunlife.ca/pshcp. To claim for surgical services, you must claim to your dental care plan (Great West Life) first. You will not receive a reply. Attach supporting documentation (original receipts, bills, invoices, physician or practitioner statements, and/or questionnaires, etc.). Here you can access forms for the Public Service Dental Care Plan (PSDCP). i understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. To avoid delay in having your claim processed, please by the subscriber or spouse, and items 13 through 21 are to be completed by the dentist. Top of Page. Many translated example sentences containing "Public Service Dental Care Plan" – French-English dictionary and search engine for French translations. The PSHCP Relief Provision application form is found on the Public Services and Procurement Canada website. PSHCP Application Forms. To ensure that you are still eligible for reimbursement, it is recommended that you regularly submit a confirmation of your ongoing treatment using the Public Service Dental Care Plan claim form. Enrolment Forms Benefit Plan Enrolment Form * Executive Government Employees. You can specify coverage percentages and/or apply a fixed dollar amount per year for the following dentalcare options: Basic coverage including ongoing care and maintenance as well as diagnostic services, such as exams, radiographs, X-rays and tests This new downloadable form gives offices the ability to appeal a denied dental claim for performing four quadrants of scaling and root planing in a single visit. If you are unsure about your level of cover and need advice call our customer service team on 1890 130 017 in advance of commencing any treatment. Some PDSP forms were made obsolete as of April 1 st 2006. Fill in your personal details below. Public Service Health Care Plan (PSHCP) Claim Form free download and preview, download free printable template samples in PDF, Word and Excel formats Please note that conditions may apply. Dental Claim Form * Great West Life Direct Deposit Authorization * Great-West Life. Learn about the Public Service Dental Care Plan (PSDCP), a mandatory dental services plan for federal public service employees and their eligible dependants for specific dental services and supplies not covered under a provincial/territorial health or dental care plan. It provides dental coverage to eligible federal pensioners and their family members who qualify, including survivors. Claim Form for Public Service Dental Care Plan (PSDCP) (PDF Document – 126 … Submit a form to upgrade your dental plan COVID-19 update: To minimize service impacts and ensure the safety of our staff, we’re not accepting paper documents. Sitemap. Ask your dentist or the receptionist to complete the back of this form and attach a receipt for the full cost of treatment. Claim form NDP005 11/2016 Page 1 of 2 We can only process claim forms that are accompanied by full proof of payment. Once you have reached your yearly maximum, further dental surgical expenses can be claimed to your medical plan, Sun Life. The Employer and the Plan Administrator have agreed, in the interest of proper plan administration, to allow a plan … Forms. Claims are made on the Public Service Dental Care Plan Claim Form (PDF Document – 126 KB) (The Great-West Life Assurance Company). Before visiting the dentist, download a Claim Form and bring this along to your visit. i hereby assign my benefits payable from this claim to the named dentist and authorize payment directly to him/her. Learn about the Pensioners' Dental Services Plan (PDSP), a voluntary dental services plan for retired members of the federal public service and their eligible dependants (family members) for specific dental services and supplies not covered under a provincial/territorial health or dental care plan. Your reimbursement will be converted to Canadian dollars. If you are already retired or become entitled to a survivor benefit, you can obtain the PDSP form from the Pension Centre. Both you and your dentist must complete the appropriate sections of the form. Member Services; Forms & Documents; Member Resources; Participating Organizations; ARTA Member Advantages; ARTA Eligibility; Retiree Benefits; Claim Forms ; Benefits Forms; ARTA Forms; Claim Forms. Please send your personal forms and paperwork through My Account Message Centre. charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. The Disability Insurance Plan claim forms below can be found on the Sun Life DI webpage: www.sunlife.ca/DI. For expenses incurred outside of Canada, indicate the currency of your expenses. Either browse through the list of forms below or use the “Search Forms” field to do a keyword search of all forms. part 1 dentist. Claims. You can quickly and easily find all of the forms you are looking for on this page. PUBLIC SERVICE DENTAL CARE PLAN AUTHORIZATION FOR CLAIMS SUBMISSION AND RE-DIRECTION OF PAYMENT POLICY STATEMENT Under the Public Service Dental Care Plan (PSDCP) rules, a member may re-direct payment of one or more claims to the member’s spouse or common-law partner. Step 1 – Before visiting the dentist. part i: to be completed by enrollee/patient . Claiming is Fast & Simple. Use this form for all medical expenses and services claims: Plan member Plan sponsor [PDF, 2 pages, 341 KB] ... Use this form for all medical & dental expenses to be claimed through your health spending account only. The calculations for these payments will be based on the information submitted by the orthodontist as described on the predetermination of benefit statement issued by Canada Life. Complete details on the PDSP are set out in the PDSP Plan Rules. Claim Form for Public Service Dental Care Plan (PDF Document – 126 KB) (The Great-West Life Assurance Company) Public Service Dental Care Plan - Authorization for Claims Submission and Redirection of Payment (PDF Document – 57 KB) (The Great-West Life Assurance Company) Pensioners’ Dental Services Plan. Dentists or dental hygienists, and dental clinics can also provide Dental Claim Forms to their patients to help them submit a claim to their dental insurance provider. This page contains forms for the public service group insurance benefit plans: the Public Service Health Care Plan (PSHCP), the Public Service Dental Care Plan (PSDCP), the Pensioners’ Dental Service Plan (PDSP), the Public Service Management Insurance Plan (PSMIP) and the Disability Insurance Plan (DI). please print. administered by: return completed form to the mailing address indicated on the member i.d. It covers you for specific dental services and supplies that are not covered under your provincial health care or dental care plan. Claims are submitted directly from the dentist so payment is easy and convenient. The Public Service Dental Care Plan (DCP) is a private health service plan for federal Public Service employees and their eligible dependants. dental claim notice . Click here to apply for the PSHCP Relief Provision, (You will be taken to the Public Works and Government Services Canada website). Claims should be forwarded to the DCP Administrator, the Public Service Health Care Plan (PSHCP) Claim Form PROTECTED once completed. There are four ways you can submit a claim: By using the PSHCP Benefit Card at participating pharmacies to obtain reimbursement for presciption drugs and certain medical supplies; The attending doctor must fully complete and sign Part 3 of the claim form; If you were treated in a public facility in an EU member state, you should apply to your local Health Board for an European Health Insurance Card prior to submitting your claim to Vhi Healthcare. Use this claim form to submit a claim for services which are covered under your dental program. Claim Form for Public Service Dental Care Plan; Government of Canada (GC) Forms Web site (accessible only on the Government of Canada network) Service Canada Forms; Canada Pension Plan and Old Age Security; Public Service Pension Plan forms; Pensioners' Dental Services Plan (PDSP) - Claim Form; Public Service Health Care Plan (PSHCP) Claim Forms; Quebec Pension Plan Source Deductions … Here you can access forms for the Pensioners’ Dental Services Plan (PDSP). Aside from this, they also have the responsibility of providing necessary information and supporting documents that the patient will have to submit to substantiate the claim. Here you can access forms for the Public Service Dental Care Plan (PSDCP). Information on the Public Service Dental Services Plan. Forms Publications . Ce formulaire est disponible en français. Most dental plans will bundle, down code, or even deny payment when four quadrants of scaling If you have any questions on Group Disability Claim, please do not hesitate to contact our customer service representatives at (852) 2519 1166 or email us by eb.claims@axa.com.hk for more information. Note that your Dental Care plan doesn't include additional coverage for dental emergencies while travelling outside Canada; however, if you have Extended Health Care coverage, you'll be eligible for additional coverage through the dental portion of your Travel Emergency benefit. Other types of eligible health care expenses can be submitted by mail using a completed PSHCP Claim Form (PDF, 614 KB) for Supplementary Coverage or a PSHCP Claim Form for Out-of-Country Claims for Comprehensive Coverage. For enquiries, contact us. Please read all instructions and information; make sure that all sections are complete and accurate or this claim will be returned to you. The Public Service Health Care Plan provides reimbursement to Plan members and their dependants for eligible expenses as defined under the Plan. public service dental care plan instructions part 1 dentist for dentist’s use only, for additional information, diagnosis, procedures, or special consideration. www.pshcp.ca/coverage/extended-health-provision/dental-benefit.aspx To apply to the PSHCP or to amend your coverage: If you are a member of the Veterans Affairs Client Group: Positive enrolment forms are available on Sun Life’s PSHCP Member Services website: www.sunlife.ca/pshcp, Veterans Affairs Canada Initial Application Form, Veterans Affairs Canada Application Amendment Form, Veterans Affairs Canada Coverage Termination Form, PSHCP Claim Form for Out-of-Country claims, © 2020 PUBLIC SERVICE HEALTHCARE PLAN. Office Forms; Claim for date of service. 1) Complete the appropriate PSHCP Claim Form: If you have Supplementary Coverage, complete the PSHCP Claim Form. i understand that i am financially responsible to my dentist for the entire treatment. For more … i understand that i am financially responsible to my dentist for the entire For more information, refer to: To apply to the PSHCP or to amend your coverage: Employee Application Form (TBS-006491) Pensioner Application Form (TBS-006492) If you are a member of the Veterans Affairs Client Group: Veterans Affairs Canada Initial Application Form. Member Forms. duplicate form i understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists and payers. How to Claim. As of January 1, 2021, claim forms can be found on MyARTA.net. 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