Fillable Extended Health Care Claim Form printable pdf download

Extended Health Care

Claim Form

GroupSource

Suite 400, 1550 - 5th Street SW

Calgary, AB T2R 1K3

Employee

Information

Policy Number

Employer Name

Employee Identification Number

Gender

Last Name

Given Name

Name Commonly Used

Male

Female

Apt. / House #

Street Address

Date of Birth

yyyy / mm / dd

City

Province

Postal Code

Daytime Tel. No./Evening Tel. No.

Spouse and

1. If you are claiming for your spouse, complete the following:

Gender

Children

Covered by

Last Name

Given Name

Name Commonly Used

Date of Birth

yyyy / mm / dd

Male

Female

this Claim

Is your spouse covered for any of these expenses under any medical plan or contract?

Yes

If yes, you should submit the claim to your spouse’s plan first.

Complete only

When your spouse’s plan is also through GroupSource, benefits can be coordinated efficiently if both claim forms are completed and submitted together.

if claim includes

2. If you are claiming for your children, complete the following:

expenses for

Relationship to

Employee

spouse or

Date of Birth

*If child is

children.

over 22,

yyyy mm

Son / Daughter

Last Name

Given Name

Name Commonly Used

supporting

documents

from the

school are

required.

Are your children covered for any of these expenses under your spouse’s medical plan or contract?

Yes

If Yes, what is the month and day of your

spouse’s birthday?

Month:

Day:

Your children must claim first under the plan of the parent with the earliest birthday (month and

day). Please see note 2 on the back of this form.

Details of

1. Are the expenses the result of an accident?

Yes

Claim

If yes, where did the accident occur?

Work

Home

Other

When did the accident occur?

yyyy / mm / dd

Attach Original

Are any expenses the result of a condition covered by Workers’ Compensation?

Yes

Receipts

2. Fill in the total of all receipts for each category.

*If this claim is for services incurred Out-of-Country, contact GroupSource for the appropriate form.

Prescription Drugs

If this claim has

IMPORTANT: If any prescription receipt is $100 or more, please indicate the number of days the prescription will last: ___________days

been submitted

Other

under another

(Please specify e.g. “paramedical services” etc.)

plan, attach

the original

Assignment of Benefits

(complete only if payment to be issued directly to the service provider)

Explanation

I hereby assign any benefits payable for eligible paramedical services, medical supplies or prescriptions provided by:

of Benefits from

Total Amount Claimed

and authorize direct payment to the provider indicated on the attached invoices.

that plan and

Employee Signature

Date Signed

copies of the

Do you want any unpaid balance from this claim reimbursed from your Health Spending Account (if eligible)?

Yes

receipts.

Authorization and Declaration

Employee

I certify that the information contained herein is true, complete and accurate and that each of the listed expenses was purchased and/or incurred in connection with medical

Signature

treatment of the above-named individuals. I acknowledge that the submission of false or incomplete information may result in the delay or denial of this claim. I authorize any

physician, dentist or any health care provider and/or facility, any insurance company, benefit service provider and any other person or organization having any medical or other

relevant personal information regarding me or my spouse and/or dependant to release to and exchange with the insurer, the group plan administrator or their representatives

and/or agents any and all information necessary to investigate and confirm the accuracy and validity of this claim, determine eligibility for benefits and/or administer the claim

and group benefit plan. I confirm that I am authorized to act on behalf of my spouse and/or dependents for such purposes. Any copy of this Authorization and Declaration

shall be as valid as the original.

Employee Signature

Date

Please note: Original signature is required on each claim form.

Date Employed

Date Covered

Date Dependent Covered

Date Terminated

Retirement Date

GroupSource is committed to protecting the confidentiality, accuracy and security of the personal information it collects and uses in the course of conducting business.

07-14.GroupSource.EHC.CLAIM

Extended Health Care Claim Form

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