Claim Form For Vision Care Services - Green Shield Canada

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CLAIM FORM FOR VISION CARE SERVICES
Please use one form per practitioner, per patient. There is no need to attach receipts if this form is completed in full by the provider.
SECTION 1 – PATIENT INFORMATION
PROVIDER INFORMATION
GREEN SHIELD ID NUMBER
COMPANY NAME
PROVIDER NUMBER
PROVIDER PHONE #
SURNAME
FIRST NAME
DATE OF BIRTH (YY/MM/DD)
PROVIDER NAME
ADDRESS
ADDRESS
CITY
PROVINCE
POSTAL CODE
CITY
PROVINCE
POSTAL CODE
SECTION 2 – MANDATORY DECLARATION
Do you have any other group insurance coverage that may include these services as benefits? YES
NO
If Yes, please provide Insurance company’s name ____________________________________________________ AND attach copy of statement from primary carrier.
If other coverage is Green Shield, indicate Green Shield ID number: _____________________________________
Date of Accident (YY/MM/DD) ___________________________________________
Is treatment due to a motor vehicle accident?
YES
NO
Is treatment required due to a work related injury?
YES
NO
Date of Injury (YY/MM/DD) _______________________________________________
Is treatment related to an open Worker’s Compensation claim?
YES
NO
SECTION 3 a – EYE EXAM CLAIM DETAILS (
)
ONLY IF INCLUDED WITH THIS SUBMISSION
PROVIDER NUMBER
OPTOMETRIST NAME, ADDRESS & PHONE NUMBER
EYE EXAM
YEAR MONTH DAY
PAY PLAN MEMBER
AMOUNT
$
PAY PROVIDER
SECTION 3b – EYEWEAR CLAIM DETAILS
CHARGES
DATE EYEWEAR RECEIVED OR PAID IN FULL: ________________________
YEAR
MONTH
DAY
FRAMES
MUST BE COMPLETED IN
SPHERE
CYLINDER
AXIS
PRISM
EYEGLASS LENSES
ALL CASES BY SUPPLIER:
CONTACT LENSES
R
New Prescription
Safety Glasses
L
DISPENSING FEE
Lenses Only
Post Cataract claim
TINT
MISC./DIAGNOSTIC TEST
PROGRESSIVE
BIFOCAL
TRIFOCAL
BIFOCAL
Colour & No
1.____________________
If Post Cataract claim,
R
R
R
2.____________________
does patient have lens
implant?
L
TOTAL
L
L
Yes
No
CONTACT LENSES:
PATIENT PAID
Yes
No
Can visual acuity be restored to at least 20/70 in the better eye with conventional eye glasses?
Yes
No
Can visual acuity be restored to at least 20/40 in the better eye with conventional eye glasses?
BALANCE TO PROVIDER
Yes
No
Are they medically necessary due to keratoconus, irregular astigmatism or irregular corneal curvature?
SECTION 4 – AUTHORIZATION
I UNDERSTAND THAT THE CHARGES LISTED IN THIS CLAIM MAY NOT BE COVERED BY OR MAY EXCEED MY BENEFIT PLAN. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO
THE SUPPLIER FOR THE COST OF THOSE SERVICES.
__________________________________________________________
SIGNATURE OF PATIENT OR LEGAL GUARDIAN
THE CHARGES LISTED ON THIS CLAIM HAVE BEEN PAID IN FULL BY THE PATIENT.
COMPLETE THIS SECTION ON THE DATE OF PICK UP.
I CERTIFY THAT THE ABOVE
PLEASE REIMBURSE PATIENT DIRECTLY.
TREATMENT WAS RENDERED AND HEREBY ASSIGN PAYMENT DIRECTLY TO THE
PROVIDER.
______________________________________________________________________________
_____________________________________________________________________________________
SIGNATURE OF PROVIDER
SIGNATURE OF PATIENT OR LEGAL GUARDIAN
By signing this claim form and/or submitting original receipts, I agree that the information provided on this form is complete and accurate. I understand that the information provided by me to
Green Shield Canada about myself and my dependents, will be used by Green Shield Canada for claims adjudication and any other services necessary in the administration of our benefits
which may include the exchange of information with other parties to administer this benefit claim. I authorize the release of the information contained on this form. I am authorized by my
spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this information may be seen by the cardholder.
SECTION 5 – MAILING INSTRUCTIONS
PLEASE ATTACH ALL ORIGINAL CORRESPONDENCE and retain copies for your files as original receipts will not be returned. ALL CLAIMS MUST BE SUBMITTED WITHIN 12 MONTHS OF THE
DATE OF SERVICE (unless otherwise stated in your benefit plan documentation). THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/PLAN
MEMBER.
CUSTOMER SERVICE CENTRE
1-888-711-1119 or (519) 739-1133
PLEASE INDICATE ON MAILING ENVELOPE:
GREEN SHIELD CANADA P.O. BOX 1615, WINDSOR, ON N9A 7J3
ATTENTION: VISION DEPARTMENT
greenshield.ca
VIS
Claim Form for Vision EN (Rev. 2013-05)

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