Coverage & Pre-Determination Request — Winnipeg Orofacial Health Centre

Submit a Pre-Determination Request

Please complete the fields below. If something is time-sensitive, call us at 204-221-6166.

Patient status

Existing patient New patient

First name

Last name

Date of birth

Contact details

Please provide at least one way to reach you if we need clarification.

Phone

Patient address

Address

Unit # (optional)

City

Province

Postal code

The policy holder is

the patient someone else

Insurance

Insurance type

Use photos instead (upload your insurance card or documents) Upload up to 3 files (PDF or images). If you use photos, you do not need insurance company, plan, or member numbers.

Insurance company

Policy #

Member ID #

I acknowledge that I have dental insurance with the plan provided and I give Orofacial Health permission to submit pre-determinations on my behalf using this information, and to store it in their system(s).

Additional Information

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