THIS IS AN ACCURATE STATEMENT OF SERVICES PERFORMED AND THETOTAL FEE DUE AND PAYABLE, ERRORS AND OMISSIONS EXCEPTED.

FOR DENTIST'S USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES, ORSPECIAL CONSIDERATION

I UNDERSTAND THAT THE FEES LISTED IN THIS CLAIM MAY NOT BE COVERED BY OR MAYEXCEED MY PLAN BENEFITS. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TOMY DENTIST FOR THE ENTIRE TREATMENT.I ACKNOWLEDGE THAT THE TOTAL FEE OF $ IS ACCURATE ANDHAS BEEN CHARGED TO ME FOR SERVICES RENDERED.I AUTHORIZE RELEASE OF THE INFORMATION CONTAINED IN THIS CLAIM FORM TO MYINSURING COMPANY / PLAN ADMINISTRATOR.

Group BenefitsStandard Dental Claim Form

CHEQUE NO.

PLAN CONTRACT NO.

PLAN MEMBER (0)SPOUSE (1)DEPENDANT (2)

PART 3 - PATIENT INFORMATION

PART 2 - PLAN MEMBER INFORMATION

PLAN MEMBER CERTIFICATE NO.

PLAN MEMBER: LAST NAME GIVEN NAME

ADDRESS (IF DIFFERENT FROM ABOVE) APT. NO.STREET NO. & NAME

CITY OR TOWN PROVINCE POSTAL CODE

PATIENT RELATIONSHIP:

SPECIFY RELATIONSHIP DAY/MONTH/YEAR

SUBMIT CLAIM TO:MANULIFE FINANCIALGROUP DENTAL CLAIMSPO BOX 400WATERLOO ON N2J 4A9

www.manulife.ca/groupbenefits/secureserve

PLAN CONTRACT NO.

SPOUSE'S DATE OF BIRTH(DAY/MONTH/YEAR)

IF YES, INDICATE INSURING COMPANY NAME:

PLAN MEMBER - PLEASE COMPLETE PARTS 2, 3, & 4 PART 4 - ADDITIONAL INFORMATION

PLAN SPONSOR NAME

HOME PHONE #

BUS. PHONE #

IS ANY OF THE ABOVE TREATMENT REQUIRED AS ARESULT OF AN ACCIDENT? YES NO

IF YES, IS THE WORKPLACE SAFETY AND INSURANCEBOARD INVOLVED? YES NO

DO YOU HAVE ANY OTHER DENTAL INSURANCECOVERAGE? YES NO

DAY MO. YEAR

DATE OF SERVICEPROCEDURE

CODE

INTL.TOOTHCODE

TOOTHSURFACES

DENTIST'SFEE

LABORATORYCHARGE

TOTAL CHARGESFOR CARRIER USEALLOWED AMOUNT INC. % PATIENT'S SHARE

DATE

DEDUCTIBLE PATIENT PAYS PLAN PAYSTOTAL FEE SUBMITTED

DUPLICATE FORM

SIGNATURE OF PATIENT (PARENT/GUARDIAN)OFFICE VERIFICATION

PATIENT - LAST NAME FIRST NAME

ADDRESS APT.

CITY PROV. POSTAL CODE

TELEPHONE NUMBER ( )

PART 1 - DENTIST

TELEPHONE ( )

DENTIST

UNIQUE NO. SPEC. PATIENT’S OFFICE ACCOUNT NO. ASSIGNMENT OF BENEFITS:I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THISCLAIM TO THE NAMED DENTIST AND AUTHORIZEPAYMENT DIRECTLY TO HIM/HER.

SIGNATURE OF PLAN MEMBER

The Manufacturers Life Insurance Company GL3733E(LH) (10/2005)

I CERTIFY THAT I, MY SPOUSE AND/OR MY DEPENDANTS OF MINOR OR MAJOR AGE ("DEPENDANTS"), HAVE RECEIVED ALLGOODS OR SERVICES CLAIMED AND THAT THE INFORMATION PROVIDED FOR THIS CLAIM IS TRUE AND COMPLETE.I AUTHORIZE MANULIFE FINANCIAL ("MANULIFE") TO COLLECT, USE, MAINTAIN AND DISCLOSE PERSONAL INFORMATIONRELEVANT TO THIS CLAIM ("INFORMATION") FOR THE PURPOSES OF GROUP BENEFITS PLAN ADMINISTRATION, AUDIT AND THEASSESSMENT, INVESTIGATION AND MANAGEMENT OF THIS CLAIM ("PURPOSES"). I AM AUTHORIZED BY MY DEPENDANTS TODISCLOSE AND RECEIVE THEIR INFORMATION, FOR THE PURPOSES. I AUTHORIZE ANY PERSON OR ORGANIZATION WITHINFORMATION, INCLUDING ANY MEDICAL AND HEALTH PROFESSIONALS, FACILITIES OR PROVIDERS, PROFESSIONALREGULATORY BODIES, ANY EMPLOYER, GROUP PLAN ADMINISTRATOR, INSURER, INVESTIGATIVE AGENCY, AND ANYADMINISTRATORS OF OTHER BENEFITS PROGRAMS TO COLLECT, USE, MAINTAIN AND EXCHANGE THIS INFORMATION WITHEACH OTHER AND WITH MANULIFE, ITS REINSURERS AND/OR ITS SERVICE PROVIDERS, FOR THE PURPOSES. I AUTHORIZETHE USE OF MY SOCIAL INSURANCE NUMBER ("SIN") FOR THE PURPOSES OF IDENTIFICATION AND ADMINISTRATION, IF MY SINIS USED AS MY PLAN MEMBER CERTIFICATE NUMBER. I AGREE A PHOTOCOPY OR ELECTRONIC VERSION OF THISAUTHORIZATION IS VALID. I UNDERSTAND THAT MANULIFE'S PRIVACY POLICY AND PRIVACY INFORMATION PACKAGE AREAVAILABLE AT WWW.MANULIFE.CA/GROUPBENEFITS, OR FROM MY PLAN SPONSOR.

ANY INFORMATION PROVIDED TO OR COLLECTED BY MANULIFE IN ACCORDANCE WITH THIS AUTHORIZATION, WILL BE KEPTIN A GROUP BENEFITS HEALTH FILE. ACCESS TO YOUR INFORMATION WILL BE LIMITED TO:• MANULIFE EMPLOYEES, REPRESENTATIVES, REINSURERS, AND SERVICE PROVIDERS IN THE PERFORMANCE OF THEIR JOBS;• PERSONS TO WHOM YOU HAVE GRANTED ACCESS; AND• PERSONS AUTHORIZED BY LAW.YOU HAVE THE RIGHT TO REQUEST ACCESS TO THE PERSONAL INFORMATION IN YOUR FILE, AND, WHERE APPROPRIATE, TOHAVE ANY INACCURATE INFORMATION CORRECTED.

PLAN MEMBER SIGNATURE DATE (DAY/MONTH/YEAR)

PATIENT DATE OF BIRTH: