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The Canadian Dental Hygienists Association/ L Association canadienne des hygi nistes dentaires 1122 Wellington St W Ottawa ON K1Y 2Y7 t 613-224-5515 x141 1-800-267-5235 f/t 613-224-7283 NATIONAL DENTAL HYGIENE CLAIM FORM PART 1 - REGISTERED DENTAL HYGIENIST / 17 3 7 17 Last Name First Address Apt. City Province Postal Code Telephone Date of Service D M Y REGISTERED DENTAL HYGIENIST USE ONLY ADDITIONAL INFORMATION OFFICE CDHA UIN 202 CDHA Service Code INTL Tooth Indicate if Preauthorization...
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