$239.00 03 Sep,2000 F 362339000 4426A 641-39 Queens Quay East Brian C. Wong 12 Yonge Street Unit 8 416--21-4-91-19 Toronto, Ontario M5E-1Z9 Toronto,ON M5E-0A5 PART 1 DENTIST UNIQUE NO. SPE C. PATIENT'S OFFICE ACCOUNT NO SIGNATURE OF SUBSCRIBER LASTNAME GIVEN NAME x SIGNATURE OF PATIENT (PARENT/GUARDIAN) OFFICE VERIFICATION DUPLICATE FORM DATE OF SERVICE DAY MO YR PROCEDURE TOTAL CHARGES IF PATIENT IS CHILD OVER 19 YEARS OF AGE STUDENT FULL TIME PART TIME DETAILS TREATMENT RESULTING FROM: ACCIDENT OCCUPATIONAL ILLNESS OR INJURY DETAILS TREATMENT INVOLVING: DENTURE CROWN BRIDGE ORTHODONTICS DETAILS DATE SIGNATURE Total Fee Submitted Part 2 - Employer / Plan Member / Subscriber and Patient Information Insurance / First Payor Co-Insurance / Second Payor Subscriber Last Name First Name BirthDay Policy No. Subscriber ID Division No. Soc. Ins. No. Employer Patient BirthDay Relationship to Subscriber Patient ID Sex Subscriber Last Name First Name BirthDay Policy No. Subscriber ID Division No. Soc. Ins. No. Employer Patient BirthDay Relationship to Subscriber Patient ID Sex Sex Sex Instruction for Claim P A T I E N T Dentist Liu Yi Qi STANDARD DENTAL CLAIM ALL INFORMATION RECORDED ON THIS FORM IS CONFIDENTIAL I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM TO THE NAMED DENTIST AND AUTHORIZE PAYMENT DIRECTLY TO HIM/HER FOR DENTIST'S USE ONLY. FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES OR SPECIAL CONSIDERATION. I UNDERSTAND THAT THE FEES LISTED IN THIS CLAIM MAY NOT BE COVERED BY OR MAY EXCEED MY PLAN BENEFITS. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO MY DENTIST FOR THE ENTIRE TREATMENT. I ACKNOWLEDGE THAT THE TOTAL FEES OF $ 239.00 IS ACCURATE AND HAS BEEN CHARGED TO ME FOR SERVICES RENDERED. I AUTHORIZED RELEASE OF THE INFORMATION CONTAINED IN THIS CLAIM FORM TO MY INSURANCE COMPANY/ PLAN ADMINISTRATOR.I ALSO AUTHORIZE THE COMMUNICATION OF INFORMATION RELATED TO THE COVERAGE OF SERVICES DESCRIBED IN THE FORM TO THE NAMED DENTIST. INTL TOOTH CODE TOOTH SURFACES DENTIST'S FEE LABORATORY CHARGE This is an accurate statement of service performed and the total fee due and payable, E & OE. I AUTHORIZE THE RELEASE OF ANY INFORMATION REQUESTED IN RESPECT TO THIS CLAIM TO THE INSURER OR ITS AGENTS AND CERTIFY THAT THE INFORMATION GIVEN IS TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE 21 Jun 2022 23312 34 DO $239.00 $239.00