Fillable Medical Expenses Claim Form - Group Insurance printable pdf download

CLAIM FORM

GROUP

MEDICAL EXPENSES

INSURANCE

According to your province of residence, please submit form to:

Claim

Estimate

Quebec

Ontario, Atlantic and Western Provinces

Group Health and Dental Claims

PO Box 800, Station Maison de la Poste

PO Box 4643, Station A

Montreal, Quebec H3B 3K5

Toronto, Ontario M5W 5E3

1. PRIMARY MEMBER INFORMATION

Member’s last name _______________________________________ First name ____________________________________________________________

Group policy no. __________________ Certificate no. ___________________ Company/Association name _____________________________________

Date of birth

Sex:

Language:

English

French

Preferred method of contact for the purpose of claims resolution:

Telephone ______________________________________

Email address __________________________________________________________

Complete this section only if your information has recently changed.

Member’s Address _________________________________________________________________________ Postal Code ______________________

2. COORDINATION OF BENEFITS

(Complete this section only if your spouse or dependent children are covered by another group plan.)

• If your spouse or dependent children are covered under their own group plan for medical benefits, the claim must first be submitted to his/her group insurance

carrier. You may subsequently submit a claim to Industrial Alliance for the unpaid portion, if applicable.

• If your insured dependent children are covered under your plan as well as under your spouse’s group plan, the claim must be submitted to the plan of the

parent whose birthday comes first during a calendar year.

Is your spouse or dependent child(ren) covered by another group plan for medical benefits?

Yes, please complete the information below.

Family, name of insured spouse/child _________________________________________ Date of birth

Health Coverage:

Individual

Are you claiming any expenses for your spouse or dependent children that are

covered under their plan?

NOT

Yes, please specify the benefit: ________________________________________________________________________________________________________

If your spouse’s group insurance carrier is also Industrial Alliance, do you want us to apply coordination of benefits?

Yes, please specify:

Spouse’s group policy no. ______________________________________________ Certificate no.___________________________________________________________

3. MEDICAL EXPENSES

• To ensure the complete resolution of your claim, please provide the required

information as outlined on the reverse side of this form.

• Attach the original receipts and keep a copy for income tax purposes

For children 18 and over

(or according to your plan)

and the coordination of benefits. The receipts will not be returned

Handicapped

Full-time

and they will be destroyed 60 days after the received date.

Total Expenses

child

student

Name of school

(per claimant)

Name

Relationship to member

Date of birth

(One line per claimant)

No Yes

___________________________ $ ___________

____________________

________________

___________________________ $ ___________

____________________

________________

___________________________ $ ___________

____________________

________________

___________________________ $ ___________

____________________

________________

If the claim is the result of an accident, please specify type of accident (details on reverse side, if applicable):

Work

Motor vehicle

Date of accident

Other _____________________

4. MEMBER CONFIRMATION/AUTHORIZATION

I HEREBY CONFIRM:

1. that the information contained in this claim form is true and complete to the best of my knowledge.

2. that the persons for whom I am making a claim are eligible and that if the claim is being made on behalf of a dependent, I am AUTHORIZED to disclose

information about him/her with respect to the claim.

On behalf of myself and my dependents:

1. I CONSENT TO THE RELEASE of the information contained in this claim form to Industrial Alliance Insurance and Financial Services Inc., its

employees, agents, reinsurers, service providers and other organizations working with Industrial Alliance for the purposes of underwriting, administration

and processing of the claim.

2. I AUTHORIZE any healthcare provider or professional, medical organization, insurance or reinsurance company, workers’ compensation board, the

policyholder, my employer, as well as any other person, private or public organization or institution to disclose to Industrial Alliance, its employees,

agents and service providers any information regarding the treatment and expenses incurred which they may need in the assessment of the claim.

3. I UNDERSTAND AND AUTHORIZE that in the event there is reasonable suspicion of or any evidence of fraud or abuse regarding the claim, Industrial

Alliance will have the right to use and exchange any information related to the claim with any relevant regulatory, investigative or government body, any

healthcare provider or professional medical organization, insurance company or reinsurer, the policyholder, my employer or any other party as provided by

law for the purpose of investigating any such fraud or abuse.

I UNDERSTAND that personal information may be subject to disclosure to those authorized under the applicable laws within or outside of Canada.

I AGREE that a photocopy of this Confirmation/Authorization shall be as valid as the original.

____________________________________________________________

Member’s signature

Date

F54-326A(15-11)