Dental Form – West Lincoln Community Care

DENTAL / VISION ASSISTANCE FORM

PERSONAL INFORMATION:

Full Name:

Income Type:

Gender: Male Female

Address:

Phone Number:

Email:

Date of Birth:

Age:

Do you have other benefits?: Yes No

Have you applied for the Canadian Dental Care Plan?: Yes No

If yes, what provider:

Other Benefit Payment Amount:

Note:

COVERAGE DETAILS:

Dental Assistance is up to $600/year for adults 18 years of age and older. Vision assistance (exams and eye wear) is up to $400/24 months. Vision Exam Assistance is for adults between 20 and 64 years of age. Eye wear assistance is for all ages.
Funds are paid directly to the Dentist, Optometrist or other eye care specialist.

Applicant Signature:

Date: