PATIENT AUTHORIZATION FOR PAYMENT OF BENEFITS TO THE DENTIST: INSURANCE INFORMATION: PRIMARY SECONDARY SUPPORT: ABC COMPANY COMPANY COMPANY ADDRESS XYZ: 2277 MAPLE AVE OAK ST. TORONTO ON L3P 5H6 LONDON ON M4R 2B6 POLICY #: INSURED NAME: ANITA LYONS MARK LYONS DATE OF BIRTH: JAN 14, 1940 FEB 20, 1941 CERTIFICATE NO: EMPLOYER: J. WICKSON &CO. LOW INC. INSURED ADDRESS: 16 FOREST DR. 16 FOREST DR. WEST HILL ON L2R 7Y3 WEST HILL ON L2R 7Y3 PATIENT RELATIONSHIP: SELF SPOUSE PATIENT INFORMATION: 1. If dependent, indicate: Student Handicapped 2. Student`s school name: 3. Is the treatment due to an accident? Yes No If yes, indicate the date of the accident: 4. Is this an initial placement for dentures, crown or bridge? Yes No If not, do you indicate the date of the first placement: 5. Is the treatment used for orthodontic purposes? Yes, no 6. I understand that the fees indicated in this right are not covered by my planning services or that they may exceed them.
I understand that I am financially responsible for the entire treatment at my dentist. It contains the processors` responses that are sent after the transaction in real time. Please note that this feature is only available through TELUS Health Solutions – Group A and Continovation Services Inc (ITRANS). In the case of attribution practices, OPBs are generally more likely to be sent to their mailboxes and should therefore check their PO Box daily. The types of responses entered in the mailbox for the dentist are listed below: a) eOB response b) Claim confirmation c) Pending transaction response d) Predetermination e) Prior confirmation f) Response Sometimes a claim or pre-determination is filed and the dentist receives a response from the network. . . .