Fillable Form Mbc 1021 - Extended Health Benefits Claim (Page 2 of 2) in pdf

Form Mbc 1021 - Extended Health Benefits Claim Page 2

Download a blank fillable Form Mbc 1021 - Extended Health Benefits Claim in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Mbc 1021 - Extended Health Benefits Claim with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

AUTHORIZATION AND CONSENT

I understand that the personal information provided herein as well as any other personal

information currently held or collected in the future by Manitoba Blue Cross and/or Blue Cross

Life Insurance Company of Canada may be collected, used, or disclosed to administer the

terms of my policy or the group policy of which I am an eligible member, to develop and

recommend suitable products and services to me, and to manage the Company’s business.

Depending on the type of coverage I carry, limited personal information may be collected from

and/or released to a third party. These include other Blue Cross organizations, licensed

physicians and/or any other healthcare professionals or institutions, health and life insurers,

government and regulatory authorities, the certificate holder of any policy under which I am a

participant and other third parties when required to administer the benefits outlined in my

policy or the group policy of which I am an eligible member.

I understand that my personal information will be kept confidential and secure. I understand

that I may revoke my consent at any time; however, if consent is withheld or revoked, the

coverage may be denied or rescinded. I understand why my personal information is needed

and am aware of the risks and benefits of consenting or refusing to consent to its disclosure.

For additional information regarding Blue Cross’ privacy policies I can contact Blue Cross at

775-0151 or at should I have questions as to the collection, use or

disclosure of my personal information.

I authorize Blue Cross to collect, use and disclose my personal information as described

above.

Form Mbc 1021 - Extended Health Benefits Claim Page 2

Related Articles

Related forms

Related Categories