CLAIM AND AUTHORIZATION FORM
PATIENT INFORMATION - MEDICAL
Date of Birth:
‘You’ or ‘Your’ refers to the primary insured named on this claim form. If the Primary insured is a minor, the parent or legal guardian is referred to as ‘You’ or Your’
Please confirm your preferred primary method of contact (select one):
If you selected ‘Home Phone’ or ‘Mobile Phone’; please advise the best time/day to be reached between Monday – Friday 8AM – 5PM EST
Enter Time: _______ AM/PM ; Circle Day: Monday Tuesday Wednesday Thursday Friday
(by selecting your preferred method of contact, you are providing consent for «ltw_text_3» to discuss your claim information via phone or email)
CANADIAN FAMILY DOCTOR AND/OR SPECIALIST INFORMATION
Your medical history may be required to fully review your claim. Please provide your Canadian physician(s) information below.
Walk-in Clinic (if applicable):
1. Trip Departure Date: _____________________
Trip Return Date: _______________________
2. The date you sought medical attention: ____________________________
3. The reason for seeking medical attention (diagnosis): ____________________________________________________________________
4. If you incurred eligible expenses and your claim is payable, please provide name and address of whom the claim should be paid out to:
OTHER INSURANCE INFORMATION
1. Please enter your Provincial Health Insurance Plan number below:
Provincial Health Insurance Plan Card #: ________________________
Version Code: ________ (Ontario Only) Some Ontario residents have 1 or 2 Alpha letter(s) added at the end of their OHIP
2. Are you, or your spouse, entitled to benefits under any other plan for the medical expenses being claimed?
If YES, please provide details below; if NO, leave blank and complete the next section;
Name of Insurance Company:
Plan member ID number:
If spouse’s plan, please provide spouse’s name: _________________________________ and date of birth: ____/____/________ (DD/MM/YYYY)
3. Do you have a Credit Card?
If YES, please provide details below:
To help you receive all additional payments you are entitled to, we will coordinate with any other potential insurers on your behalf. We will determine if
the card provides coverage for your incident.
Credit Card Number:
Type of Credit Card:
PLEASE CONFIRM BOTH SIDES OF THE CLAIM FORM ARE COMPLETED