Fillable Extended Health Care Claim Form (Page 2 of 2) in pdf

How to Claim

Extended Health Care Benefits

Before completing the form...

If you are claiming expenses for your spouse who is covered under another medical plan, submit the claim for

your spouse’s expenses to your spouse’s plan first. Please include a copy of what the other plan paid when

claiming your spouse’s expenses on your plan.

If both you and your spouse have medical coverage, expenses for your children must be claimed under the

plan of the parent with the earliest birthday (month and day) in the calendar year. For example, if your birthday

is May 1st and your spouse’s birthday is June 5th, your children’s expenses will be claimed under your plan

first.

You do not have to submit a claim every time an expense occurs. You may hold your expense receipts until

they represent a significant amount, or are more than your deductible, if applicable. You should keep in mind

that there is a deadline for submitting your expense receipts to GroupSource. To find out what the deadline

is, look in your employee booklet or talk to your employer. If your Extended Health Care coverage ends for

any reason, your claim for expenses incurred while coverage is in place must be submitted to and received by

GroupSource within 90 days of your coverage ending.

After completing the form...

Please make sure that you have filled in all the information completely and signed the form. Incomplete forms

will delay the processing of your claim.

Attach original receipts for expenses and keep copies for your records. Original receipts will not be returned.

You will receive an Explanation of Benefits for income tax purposes. If any expense has been submitted

previously under another plan, attach the original Explanation of Benefits from that plan and copies of the

receipts. Your receipts should include the name of the patient, the nature of the treatment or medical product,

the name of the prescribing physician, the date, and the amount charged.

Attach a written statement from the referring doctor if you are claiming for certain medical services or expenses

such as medical equipment, nursing services, or massage therapy. The written statement should confirm why

the services were medically necessary and how long the services were needed. If the expenses were the result

of a dental accident, X-rays taken after the accident and before any treatment are required.

Mail forms to...

GroupSource

Ph: (403) 228-1657

Fax: (403) 228-1775

Suite 400, 1550 - 5th Street SW

Toll Free: 1-866-862-5246

Calgary, AB T2R 1K3

Extended Health Care Claim Form Page 2