For enquiries, contact us. The PSHCP Relief Provision application form is found on the Public Services and Procurement Canada website. 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. ADA Dental Claim Form The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. The PSHCP Relief Provision application form is found on the Public Services and Procurement Canada website. 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. 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. How to Claim. Your reimbursement will be converted to Canadian dollars. 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. i understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. Service Centre Contact Information. Enrolment Forms Benefit Plan Enrolment Form * Executive Government Employees. You can quickly and easily find all of the forms you are looking for on this page. 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. Forms Publications . The Disability Insurance Plan claim forms below can be found on the Sun Life DI webpage: www.sunlife.ca/DI. 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. 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. www.pshcp.ca/coverage/extended-health-provision/dental-benefit.aspx 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. Please note that conditions may apply. Member Forms. Here you can access forms for the Public Service Dental Care Plan (PSDCP). Public Employees Benefits Agency 110 - … 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. It provides dental coverage to eligible federal pensioners and their family members who qualify, including survivors. The Employer and the Plan Administrator have agreed, in the interest of proper plan administration, to allow a plan … 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. 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. You will not receive a reply. 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. To claim for surgical services, you must claim to your dental care plan (Great West Life) first. The Public Service Dental Care Plan (DCP) is a private health service plan for federal Public Service employees and their eligible dependants. Claims should be forwarded to the DCP Administrator, the 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. 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. Member Services; Forms & Documents; Member Resources; Participating Organizations; ARTA Member Advantages; ARTA Eligibility; Retiree Benefits; Claim Forms ; Benefits Forms; ARTA Forms; Claim Forms. part i: to be completed by enrollee/patient . 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). i hereby assign my benefits payable from this claim to the named dentist and authorize payment directly to him/her. Claims are submitted directly from the dentist so payment is easy and convenient. 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