Form Mbc 1021 - Extended Health Benefits Claim

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EXTENDED HEALTH BENEFITS CLAIM FORM
PLEASE READ CAREFULLY BEFORE COMPLETING THE CLAIM. FAMILY MEMBERS MAY SUBMIT A COMBINED CLAIM.
• COMPLETE THE CLAIM BY ENTERING THE APPROPRIATE AMOUNT
• FOR BENEFITS ASSIGNED TO PROVIDERS, ENCLOSE ITEMIZED
IN THE SPACES BELOW.
STATEMENTS FOR EACH SERVICE.
• ENCLOSE ITEMIZED RECEIPTS FOR EACH SERVICE.
• CLAIMS MUST BE SUBMITTED WITHIN 2 YEARS OF DATE OF
SERVICE, UNLESS OTHERWISE STATED IN POLICY PROVISIONS.
• RECEIPTS WILL NOT BE RETURNED — PLEASE KEEP COPIES FOR
YOUR RECORDS. LEGIBLE PHOTOCOPIES MAY BE SUBMITTED IN
• PLEASE RETAIN OUR EXPLANATION OF BENEFITS FOR
PLACE OF ORIGINALS.
COORDINATION OF BENEFITS OR INCOME TAX PURPOSES.
GROUP
BLUE CROSS CONTRACT NO.
SURNAME
CLAIMANT FIRST NAME
BIRTH DATE
DAY
MONTH
YEAR
HAS YOUR ADDRESS
STREET, P.O. BOX NO
CITY/TOWN
PROVINCE
POSTAL CODE
CHANGED?
YES
NO
WAS TREATMENT THE RESULT OF
IF CLAIMANT IS A DEPENDENT CHILD OVER THE AGE OF 18 PLEASE COMPLETE
AN INJURY AT THE WORK PLACE?
YES
NO
THE FOLLOWING:
A MOTOR VEHICLE ACCIDENT?
YES
NO
1. AGE OF CHILD
ARE ANY BENEFITS OR SERVICES PROVIDED UNDER
2. IS HE/SHE MARRIED?
YES
NO
ANY OTHER INSURANCE OR PLAN FOR THE EXPENSES CLAIMED?
IF YES, DATE OF MARRIAGE
YES
NO
IF YES, COMPLETE THE FOLLOWING
DD
MM
YR
POLICY HOLDER OF OTHER PLAN
3. IS HE/SHE EMPLOYED FULL-TIME?
YES
NO
BIRTH DATE
/
/
IF YES, DATE FULL TIME EMPLOYMENT STARTED
DAY
MONTH
YEAR
DD
MM
YR
EMPLOYER
4. IS HE/SHE IN FULL-TIME ATTENDANCE AT SCHOOL
EMPLOYER'S INSURANCE COMPANY
COLLEGE, OR UNIVERSITY?
YES
NO
POLICY OR CONTRACT NUMBER
5. IS HE/SHE PHYSICALLY OR MENTALLY INCAPACITATED
IF BLUE CROSS IS SECOND INSURER PLEASE ATTACH A STATEMENT OF
AND DEPENDENT ON YOU FOR SUPPORT?
YES
NO
PAYMENT OR DENIAL FROM FIRST INSURER AND COPIES OF THE RECEIPTS.
TOTAL
TOTAL
BENEFITS CLAIMED
AMOUNT
BENEFITS CLAIMED
AMOUNT
(ENCLOSE OFFICIAL PHARMACARE
DRUGS
RECEIPTS OR A PHOTOCOPY)
OTHERS (PLEASE SPECIFY)
IS PAYMENT TO BE MADE TO THE PROVIDER OF SERVICE?
YES
NO
I HEREBY ASSIGN BENEFITS TO THE FOLLOWING PROVIDER:
PROVIDER NUMBER
NAME
ADDRESS
POSTAL CODE
I UNDERSTAND THAT THE CHARGES LISTED MAY NOT BE COVERED BY OR MAY
EXCEED MY POLICY BENEFITS. I UNDERSTAND THAT I AM FINANCIALLY RE-
I CERTIFY THAT I AM AWARE OF AND HAVE READ THE AUTHORIZATION AND
SPONSIBLE TO THE ABOVE PROVIDER FOR THE COST OF TREATMENT.
CONSENT ON THE REVERSE SIDE OF THIS CLAIM FORM. I AGREE THAT THIS
SUBSCRIBER'S SIGNATURE _____________________________________________
CLAIM IS TRUE AND CORRECT AND AGREE THAT IT SHALL BE SUBJECT TO THE
PROVISIONS OF THE CONTRACT.
BLUE CROSS OFFICE USE ONLY
RECEIVED
ASSESSED
SIGNATURE OF PATIENT
(OR PARENT/GUARDIAN) ________________________________________________
DATE:
DATE:
(PLEASE SIGN HERE)
CHECKED
AUDIT
DATE
DATE:
INIT.
DATE:
INIT.
The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross Plans. Licensed to the Manitoba Blue Cross Plan.
®
P.O. BOX 1046, WINNIPEG, MANITOBA R3C 2X7 PHONE 775-0151 OR TOLL FREE WITHIN MANITOBA 1-800-USE-BLUE (1-800-873-2583)
MBC 1021-pdf-10/2009

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