Form 975E "Healthy Smiles, Clear Vision Application Form" - New Brunswick, Canada

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Download Form 975E "Healthy Smiles, Clear Vision Application Form" - New Brunswick, Canada

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Reset
Healthy Smiles,
m New Application
m Renewal
m Change Request
Clear Vision
(please indicate changes in applicable
Application Form
section of the form)
How to reach us
?
Please mail or fax completed application to:
Contact Information
Healthy Smiles, Clear Vision
Telephone number: 506-867-6026
644 Main Street, P.O. Box 220
Toll free number: 1-855-839-9229
Moncton, NB, E1C 8L3
Fax: 506-867-4651
Plan Information
?
Healthy Smiles, Clear Vision is a dental and vision plan that provides coverage for specified dental and vision benefits to
children who are 18 years of age and under in families with a total annual net income (after taxes) less than the limits listed below:
Family Size
.................
Income
Family Size
.................
Income
Family Size
.................
Income
5 people ...................... $42,577
7 people……………... $50,378
2 people ...................... $26,928
3 people ...................... $32,980
6 people……………... $46,641
8 people……………... $53,856
4 people ...................... $38,082
Note: Children 19 years of age or older are not included when determining family size.
Eligibility Criteria
?
To be eligible you must:
Documents to be provided:
- currently reside in New Brunswick.
- copies of 2 pieces of identification for each child (NB Medicare
- have dependent child(ren) aged 18 years or under.
card plus an additional piece of identification for each child).
- not have dental and vision coverage through any
- copy of New Brunswick Income Tax return(s) or Notice of
other government program or private insurance
Assessment(s) for parent/guardian and spouse or common-law
plan.
partner (if applicable).
Parent/Guardian Information (please print)
1
Last Name:
First Name:
Middle Name:
Social Insurance Number:
Medicare Number:
Telephone Number:
Alternate Telephone Number:
Residency - Are you a resident of New Brunswick?
m Yes
m No
ADDRESS
Building number and street:
Apt.:
City/town:
Province:
Postal code:
Dependents: Please include all dependent children 18 years or under residing with you. Please attach copies of
2 pieces of identification (one must be NB Medicare card) for each child listed. (If more space is required, please
attach separate sheet).
Last Name
First Name
Date of Birth
Gender
New Brunswick
(Day/Month/Year)
(M or F)
Medicare Number
page 1 of 2
Healthy Smiles, Clear Vision is administered by Medavie Blue Cross on behalf of the Government of New Brunswick
Reset
Healthy Smiles,
m New Application
m Renewal
m Change Request
Clear Vision
(please indicate changes in applicable
Application Form
section of the form)
How to reach us
?
Please mail or fax completed application to:
Contact Information
Healthy Smiles, Clear Vision
Telephone number: 506-867-6026
644 Main Street, P.O. Box 220
Toll free number: 1-855-839-9229
Moncton, NB, E1C 8L3
Fax: 506-867-4651
Plan Information
?
Healthy Smiles, Clear Vision is a dental and vision plan that provides coverage for specified dental and vision benefits to
children who are 18 years of age and under in families with a total annual net income (after taxes) less than the limits listed below:
Family Size
.................
Income
Family Size
.................
Income
Family Size
.................
Income
5 people ...................... $42,577
7 people……………... $50,378
2 people ...................... $26,928
3 people ...................... $32,980
6 people……………... $46,641
8 people……………... $53,856
4 people ...................... $38,082
Note: Children 19 years of age or older are not included when determining family size.
Eligibility Criteria
?
To be eligible you must:
Documents to be provided:
- currently reside in New Brunswick.
- copies of 2 pieces of identification for each child (NB Medicare
- have dependent child(ren) aged 18 years or under.
card plus an additional piece of identification for each child).
- not have dental and vision coverage through any
- copy of New Brunswick Income Tax return(s) or Notice of
other government program or private insurance
Assessment(s) for parent/guardian and spouse or common-law
plan.
partner (if applicable).
Parent/Guardian Information (please print)
1
Last Name:
First Name:
Middle Name:
Social Insurance Number:
Medicare Number:
Telephone Number:
Alternate Telephone Number:
Residency - Are you a resident of New Brunswick?
m Yes
m No
ADDRESS
Building number and street:
Apt.:
City/town:
Province:
Postal code:
Dependents: Please include all dependent children 18 years or under residing with you. Please attach copies of
2 pieces of identification (one must be NB Medicare card) for each child listed. (If more space is required, please
attach separate sheet).
Last Name
First Name
Date of Birth
Gender
New Brunswick
(Day/Month/Year)
(M or F)
Medicare Number
page 1 of 2
Healthy Smiles, Clear Vision is administered by Medavie Blue Cross on behalf of the Government of New Brunswick
Health Insurance Coverage*
2
Do your dependent children currently have health insurance coverage through a government program or private
insurer?
m Yes
Name of Insurer:
Policy Number:
m No
Does the policy include coverage for dental and/or vision benefits?
m Yes
If yes, please indicate:
m Dental coverage
m Vision coverage
m Both
m No
* Please note: For children with dental and vision coverage through the Department of Social Development,
coverage will automatically be transferred to the Healthy Smiles, Clear Vision plan and, as such, there is no need
for Social Development clients to make application to this plan.
Total Annual Net Income
3
Please provide a copy of the New Brunswick Income Tax return(s) or Notice of Assessment(s) for the parent/guardian
(and spouse or common-law partner if applicable).
Are you living with a spouse or common-law partner?
m Yes
Name of spouse or
Spouse/Common-law partner’s
common-law partner:
Social Insurance Number:
m No
Parent/Guardian’s Income
f
(Line 23600 of Notice of Assessment or
Income Tax Return from previous year).
Please include a copy.
Spouse or common-law partner’s
f
(Line 23600 of spouse’s or common-law partner’s
income (If applicable)
Notice of Assessment or Income Tax Return
from previous year). Please include a copy.
Total combined net income from
f
Add Lines 1 and 2.
previous year
Declaration and Consent
4
I/We declare that the information provided on this application is accurate and true to the best of my/our knowledge.
I/We understand that giving false or incomplete information may result in termination or suspension of benefits.
I/We understand that this information will be used to determine eligibility for dental and vision coverage under the Healthy Smiles,
Clear Vision plan and may be subject to verification by officials of Medavie Blue Cross.
I/We understand that eligibility for the Healthy Smiles, Clear Vision plan is based on annual net income and, therefore, I/we must
reapply on a yearly basis.
I/We consent to Medavie Blue Cross using the information provided on this application, including my/our social insurance number(s)
and on any document attached, for the purpose of verifying eligibility for the Healthy Smiles, Clear Vision plan. This includes
sharing the information with the Canada Revenue Agency and any other entity identified by Medavie Blue Cross and collecting
information from those entities.
Name of Applicant (please print):
Signature of Applicant:
Date:
Name of Spouse/Common-law
partner (if applicable) - (please print):
Signature of Spouse /
Common-law partner (if applicable):
Date:
page 2 of 2
Healthy Smiles, Clear Vision is administered by Medavie Blue Cross on behalf of the Government of New Brunswick
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