Claim And Authorization Form Page 2

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LIST OF SUBMITTED EXPENSES – MEDICAL
«
List eligible expenses you paid for below: (i.e. prescriptions,
Currency Expenses
Original Receipts
Date Incurred
Amount
Dr. visit, meals, ambulance, etc.)
Paid in
Enclosed Y/N
* Please attach another sheet if your expenses exceed the space provided
* If your expenses are in more than one currency, please total each separately
Total Amount: ___________ Currency:__________
Total Amount: ___________ Currency:__________
AUTHORIZATION
The following authorization statements are providing Assured Assistance Inc. authorization to obtain, recover and forward information, payments
and/or obtain recovery from your Provincial Health Insurance Plan , Extended Health benefits company and/or other sources on your behalf.
Provincial Health Insurance Plan Authorization and Release
I agree that, pursuant to the terms of this policy and in respect of my applicable provincial health insurance legislation pertaining to freedom of
information and protection of privacy; and in consideration for any monies Assured Assistance Inc. may advance to me as a result of the issuance of
this policy, I hereby irrevocably:
1. direct and authorize Provincial Health Insurance Plan to make payment in respect of my claim for out-of-country health services to Assured
Assistance Inc. directly and I hereby release Provincial Health Insurance Plan upon payment to Assured Assistance Inc. from any further claim or
cause of action in connection therewith; and
2. consent and authorize Provincial Health Insurance Plan to directly collect information contained in the claim and source documents (pursuant to
section 39(1) of the Freedom of Information and Protection of Privacy Act, and 4(2) of the Health Insurance Act, in Ontario only, and
3. consent to the disclosure by Provincial Health Insurance Plan to Assured Assistance Inc. of such personal information as may be necessarily
required for the processing of my claim for out-of-country health services, including the details of any duplicate payment made directly to me or on
my behalf.
4. I authorize you to give Assured Assistance Inc. any and all information you have regarding me, while under observation or treatment by you,
including my medical history, diagnoses and test results, and I hereby consent to the disclosure of such information by Assured Assistance Inc. to
other sources as may be required for the processing of my claim for benefits obtainable from other sources.
5. I understand my claim may be subject to review and investigation and I give Assured Assistance inc. or their authorized agents authority to acquire
any documents or statements from other insurers, financial institutions, travel suppliers, any company or public/private organization which can
provide information related to my claim, and I hereby consent to the disclosure of such information by Assured Assistance Inc. to other sources as
may be required for the processing of my claim.
6. I hereby assign to Assured Assistance Inc. any benefits obtainable from other sources for losses covered under this policy. I also direct these
sources to forward payment to Assured Assistance Inc. for my claim submitted by Assured Assistance Inc. with regard to these losses. A
photocopy or faxed copy of this authorization is acceptable.
Print Name of Claimant/Designated Legal Representative
Signature of Claimant/Designated Legal Representative
Date
If patient is a minor the Parent or Legal Guardian must sign this section on his/her behalf. If a legal representative, other than the
patient’s legal guardian signs this form, proof of “Legal Representative status” is required i.e. (Power of Attorney, Will, etc.).
A copy of this authorization shall have the same authority as the original.
Please send the required forms and documents to the following mailing address:
Assured Assistance Inc.
P.O. Box 97
Station A,
Mississauga, ON, L5A2Y9
PLEASE CONFIRM BOTH SIDES OF THE CLAIM FORM ARE COMPLETED

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