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Date of Service	Procedure Code	Intl. Tooth Code	Tooth Surfaces	Dentist's Fee	Laboratory Charge	Total Charges	Details
15-Apr-2014	11112			100.00	0.00	100.00
Total Fee Submitted $ 100.00

Date of Service	Procedure Code	Intl. Tooth Code	Tooth Surfaces	Dentist's Fee	Laboratory Charge	Total Charges	Amount paid by another insurance plan	Details
15-Apr-2014	11112			100.00	0.00	100.00	0.0
Total Fee Submitted $ 100.00

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If denture, crown, or bridge, is this an initial placement?

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I certify that the information provided for the claim(s) being submitted is true, accurate and complete and that I, my spouse and/or my dependants have received all goods or services as claimed.

I understand and acknowledge that submission of a claim determined by Manulife to be false or misrepresented will be reported, together with any related information/documentation, to my plan sponsor. I understand and acknowledge that Manulife may refer any claims it has determined were falsely submitted to law enforcement authorities for possible prosecution. Manulife will pursue the recovery of any money that has been obtained improperly through false claim submission.

I understand that I am required to keep the original claim receipts for 12 months following the date of this online claim submission for audit purposes. These receipts could be requested at any time during this period.

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Any Information provided to or collected by Manulife in accordance with this online authorization, will be kept in a Group Benefits health file. Access to your Information will be limited to:

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You have the right to request access to the personal information in your file, and, where appropriate, to have any inaccurate information corrected.

Submit a claim

Step 2 / 3 - Expenses

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