Home > First Nations & Inuit Health > Non-Insured Health Benefits > Health Provider Information > Resources & Forms > Non-Insured Health Benefits - DENT-29 Form

Non-Insured Health Benefits (NIHB) DENT-29 Form

Help on accessing alternative formats, such as PDF, MP3 and WAV files, can be obtained in the alternate format help section.

This HTML document is not a form. Its purpose is to display the information as found on the form for viewing purposes only. If you wish to submit a form, you must use only the PDF version.

(23K)

Protected when completed

For post approval
For basic or emergency services only

For predetermination

For Claim

Part 1 - Provider (Provider To Complete)

Client

Surname:
Given Names:
Address:
Apt.:
City:
Prov.:
Postal Code:

Provider No.:
(Provider)
Phone No.:

Payment will be made to the provider unless indicated below.

Pay Client/Guardian:

Please provide payee name and address if different from client. Payee must be 16 years of age.

Surname:
Given Names:
Address:
Apt.:
City:
Prov.:
Postal Code:

Office verification/signature of provider:

For provider use only - for additional information, Diagnosis, Procedures or special consideration

I authorize the release of any records that are relevant to the processing and payment of this claim, held by the service provider to Health Canada, its agents or contractors, or any appropriate health professional licensing or regulatory body for the purposes of administrative audit.

Signature of client (parent/guardian):

Date Of Service: DDMMCCYY
Procedure Code:
Int. Tooth Code:
Tooth Surfaces:
This is an accurate statement of services performed and the total fee due and payable

Professional Fee:
Laboratory Fee:
Total Fee:
$ Total Fee Submitted:

Predetermination/preverification No.:
FNIHB Approved: Yes | No | N/A | AC
Services will be reimbursed according To the applicable fnihb terms and conditions.

Part 2 - Client Information (Provider To Complete)

Client Identification No.:
Date of Birth: Day / Month / Year

Band No.:
And
Family No.:
Two fields above do not apply to Inuit and Innu clients.

Part 3 - Additional Information (Provider To Complete)

A. Are any dental benefits or services provided under any other group insurance or dental plan, W.C.B., Government Plan; Or if a result of an accident, a motor vehicle or accident insurance plan? Yes | No

If yes, please provide
Policy Number:
Name of Insuring Plan or Agency:

B. Are there any missing teeth? Yes | No
If yes, circle tooth number(s)

18 17 16 15 14 13 12 11
21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41
31 32 33 34 35 36 37 38

55 54 53 52 51
61 62 63 64 65
85 84 83 82 81
71 72 73 74 75

Part 4 - Predetermination (To Be Completed by FNIHB)

The above submission is: Approved | Not Approved

FNIHB Authorizing Officer:
CR Number:
Date: Day / Month / Year
Signature:

No.
A
Please quote this number on Your claim if FNIHB redetermination/ Preverification has been provided.

NIHB DENT29E (Printed 03/05)

For mailing instructions please see reverse

Version Date: 03/04/05

Ce formulaire est aussi disponible en Français

Instructions For Claim Submission

For reimbursement of claims please send top copy to:

First Canadian Health
3080 Yonge Street
Suite 3002
Toronto, On M4N 3N1
1-888-471-1111

Instructions For Submission Of Requests For Treatment Requiring Predetermination

Applications for treatment requiring predetermination please submit all copies to the regional First nations and inuit Health branch office, attention of regional dental officer, as listed below:

FNIHB Atlantic Region
First Nations And Inuit Health Branch
Health Canada
Maritime Centre
1505 Barrington Street
15th Floor Suite 1525
Halifax, NS B3J 3Y6
1-800-565-3294
(In Halifax) 426-4298
Fax: 1-902-426-8675

FNIHB Québec Region
First Nations And Inuit Health Branch
Health Canada
Complexe Guy-Favreau
200 West René Lévesque Boulevard
East Tower, Suite 216
Montréal, QC H2Z 1X4
1-877-483-5501
(in Montréal) 283-5501

FNIHB Ontario Region
First Nations And Inuit Health Branch
Health Canada
Emerald Plaza
1547 Merivale Road
3rd Floor, Postal Locator 6103A
Nepean, On K1A 0l3
Dental Inquiries: 613-952-0102
1-888-283-8885

Orthodontic Review Centre
Non-insured Health Benefits
First Nations And Inuit Health Branch
Health Canada
Graham Spry Building
250 Lanark Avenue, 6th Floor
Postal Locator 2006C
Ottawa, On K1A 0K9
Toll Free # 1-866-227-0943
Toll-free Fax 1-866-227-0957

FNIHB Manitoba Region
First Nations And Inuit Health Branch
Health Canada
Stanley Knowles Federal Building
391 York Avenue
Suite 300
Winnipeg, MB R3C 4W1
1-877-505-0835
(In Winnipeg) 983-3910, 983-3912
Fax: 204-984-5798

FNIHB Saskatchewan Region
First Nations And Inuit Health Branch
Health Canada
Château Tower
1920 Broad Street
18th Floor
Regina, Sk S4P 3v2
1-877-780-5458
(in Regina) 780-5458

FNIHB Alberta Region
First Nations And Inuit Health Branch
Health Canada
Canada Place
9700 Jasper Avenue
Suite 730
Edmonton, AB T5J 4C3
1-888-495-2516
(from Outside Of Alberta) 780-495-2516

FNIHB Pacific Region
First Nations And Inuit Health Branch
Health Canada
Federal Building
757 West Hastings Street
Suite 540
Vancouver, BC V6C 3E6
1-888-321-5003
Fax: 604-666-5815

FNIHB Yukon
First Nations And Inuit Health Branch
Health Canada
14th Floor, Postal Locator 3914A
Sixty Queen Building
60 Queen Street
Ottawa, ON K1A 0K9
1-888-332-9222
Fax: 1-800-949-2718

FNIHB Northwest Territories
First Nations And Inuit Health Branch
Health Canada
14th Floor, Postal Locator 3914A
Sixty Queen Building
60 Queen Street
Ottawa, ON K1A 0K9
1-888-332-9222
Fax: 1-800-949-2718

FNIHB Nunavut
First Nations And Inuit Health Branch
Health Canada
14th Floor, Postal Locator 3914A
Sixty Queen Building
60 Queen Street
Ottawa, ON K1A 0K9
1-888-332-9222
Fax: 1-800-949-2718


	Last Updated: 2006-03-21		Important Notices