CDCP Agreement | Ottawa Valley Denture Clinic

Canadian Dental Care Plan (CDCP)

Information and Agreement

The Canadian Dental Care Plan (CDCP) aims to help cover costs of various oral health care services and reduce financial barriers to accessing care for eligible Canadian residents who do not have access to dental coverage.

The CDCP will only pay for oral health care services covered within the plan at the established CDCP fees. These fees are not the same as the fees of the dental and denturist clinics. Individuals covered under the CDCP may have to pay any additional costs directly to the oral health provider.

I acknowledge that I have read and understand the statement above.
Signature(Required)
You may have to pay additional charges directly to the oral health provider if:
- Your adjusted family net income is between $70,000 and $89,999, as you will have a co-payment*
- Your oral health provider charges more than the established CDCP fees
- You and your oral health provider agree to services that the CDCP does not cover (you will need to pay the full cost of these services).
*A co-payment is the percentage of the CDCP fees that isn’t covered by the CDCP, and that you will have to pay directly to the oral health provider. Your co-payment is based on your adjusted family net income.

Before receiving oral health care, clients covered under the CDCP should always confirm what costs, if any, will not be covered by the CDCP. Anyone receiving services not covered by the CDCP will need to pay the full cost of these services.

Patients covered under the CDCP will be reassessed annually by the appropriate government authority to confirm they still meet the eligibility criteria.

Provider appointment cancellation/no-show fees cannot be billed to the CDCP. Therefore, patients will be responsible for covering these fees.

Sunlife is the CDCP Benefit Administrator on behalf of Health Canada. All claims and plan verification will be submitted or communicated to Sunlife by the provider. As such, we would require consent to facilitate claims verification and electronic submission.
- I authorize release to my benefits plan administrator information contained in claims submitted electronically.
- I also authorize the communication of information related to the coverage of services described to the named denturist.
- This authorization shall continue in effect until the undersigned revokes the same.
Name of patient, decision maker(Required)
First Last
Signature(Required)
To ensure that the coverage amount, co-payments, and coordination of benefits are accurate, it is important for your oral health care provided to know of any additional programs that you are enrolled in. Are you currently on any other federal or provincial programs?(Required)
- Yes
- No
which one?(Required)
By signing this agreement, you agree to the following:
- I have received a welcome package from Sunlife with a valid CDCP coverage, a member card, and coverage start date.
- I assume responsibility for all fees not covered by CDCP: co-payments, balance billing and no-show fees.
- I will be responsible for any fees not payable by Sunlife due to any misrepresentation in coverage.
Name of person completing this form(Required)
First Last
Signature(Required)

Ottawa Valley Denture Clinic
186 Pembroke Street West,
2nd Floor
Pembroke, ON K8A 5M8

613-735-4034
[email protected]

Canadian Dental Care Plan (CDCP)

Information and Agreement