Fillable Healthcare Claim Form printable pdf download

–

HEALTHCARE CLAIM FORM

You may fill out the form online and print

Reset Values

it or print the form and fill it out by hand.

EMPLOYEE STATEMENT

Group Contract Number ___________________________

Certificate Number _____________________________________________________________

Employer ___________________________________________________________________________________________________________________________

Employee Last name and given name ___________________________________________________________________________________________________

Date of Birth : day ________ / month ________ /year ________

Sex F 

M 

Employee Address: __________________________________________________________________________________________________________________

WOULD YOU LIKE YOUR CLAIMS PAYMENTS DEPOSITED DIRECTLY INTO YOUR BANK ACCOUNT? Yes, I am attaching a void cheque in order to benefit

from that service. Once you have provided a void cheque, only send another void cheque if you change your bank information.

COORDINATION OF BENEFITS

1. Does your spouse and/or children have coverage under any other medical plan or contract?  Yes

 No

If yes, please complete the following:

Spouse’s date of birth (D/M/Y) ____________________________________________________

Insurance company, policy number and certificate number ______________________________________________________________________________

2. Is any expense the result of an accident?  Yes

 No

If yes, please complete the following: Date _______________________________ Location of accident Work  Home  Other 

Explain how the accident occurred ___________________________________________________________________________________________________

3. If this claim is for a child 21 years of age or older, please indicate the following:

Is the child handicapped 

Is the child a full time student 

DRUGS, VISION CARE, PARAMEDICAL SERVICES AND OTHERS PATIENT INFORMATION

Date of birth

REMINDER

Total charge

Patient’s name

Relationship to plan member

(Use one line per patient)

Day

Month

Year

PLEASE REFER TO YOUR

EMPLOYEE SUMMARY OF

BENEFITS TO CONFIRM

THE AMOUNT OF TIME

YOU HAVE TO SUBMIT A

CLAIM.

THIS FORM MUST BE

COMPLETED IN FULL.

INCOMPLETE FORMS

WILL BE RETURNED TO

YOU, WHICH WILL

DELAY THE PROCESSING

PRESCRIPTION DRUGS

TOTAL FEE SUBMITTED

OF THE CLAIM.

Please attach your original receipts to the back of this form. All drug receipts must contain the drug identification and the

name of the prescription drug.

VISION CARE ASSIGNMENT OF BENEFITS

Name and address of provider:

I hereby assign my benefits payable from this claim to the named provider and

authorize payments directly to him/her.

________________________________________________________________________________________

Telephone:

Signature of employee

Date

AUTHORIZATION

Personal information we collect from you is kept in strict confidence and will be used to assess your claim and to administer the group benefit plan. I

authorize the use of my certificate number as an identification number where it is required in the administration of my group benefit plan. I authorize

Cowan, any healthcare provider, my plan administrator, other insurance companies, other organizations, or benefit service providers working with

Cowan to exchange information when necessary to assess my claim and to administer the group benefit plan.

I certify that the information given is true, correct and complete to the best of my knowledge.

Signature of employee ________________________________________________________

Date _________________________________________

MAIL YOUR COMPLETED FORM TO THE FOLLOWING ADDRESS:

Cowan Insurance Group

700-1420 Blair Place

Ottawa, Ontario K1J 9L8

Telephone: 1-888-509-7797 or 1-613-741-3313