Fillable Extended Health Claim Form Pacific Employee Benefits printable pdf download

Extended Health Claim Form Pacific Employee Benefits

Download a blank fillable Extended Health Claim Form Pacific Employee Benefits 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 Extended Health Claim Form Pacific Employee Benefits 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.

Extended Health Claim Form

Send claims to:

PO Box 3249, 3756 First Avenue, Smithers,BC V0J 2N0

Please check which plan you have:

ASO

HCSA

PHSP

Instructions:

Attach the bills, original receipts and Dental claim forms for dental,for all expenses and itemize them by providing all the information requested. Note: Drug bills

receipts, other than those required for government drug plans, are part of our records and will not be returned. Therefore, please retain the itemization or exp

that will accompany our cheque for Income Tax Purposes.

Important:

Please answer all questions. This claim may be returned to you if it is incomplete or contains errors.

Please Print

Part 1: Employee's Statement

Plan Number

Employee ID#

Employer Company Name

Employee Name

Phone Number

Home:

Work:

Mailing Address

City

Province

Postal Code

Email Address

Please indicate if this is a new address to be updated in the system:

Yes_______ No_______

Part 2: Coordination of Benefits

Are you or any other member of your family entitled to benefits under this or any other plan?

Yes __________ No___________

If "Yes", name of family member insured ____________________________________________ Relationship to employee____________________________

Name of insurance company______________________________ Policy number _________________

Coverage: Family __________ Single__________

If "Family" coverage is specified, and the patient for this claim is a dependant child, please provide spouse's Date of Birth ___________________(yy/mm/dd)

Is a treatment required as the result of a motor vehicle accident?

Yes __________ No___________

Is a claim being made for Worker's Compensation Benefits?

Yes __________ No___________

Part 3: Claim Details

Drug Expenses

Other Expenses

Patient Name

Number of Receipts

Total Charge

Type of Expense

Total Charge

If Additional Space is needed, Attach separate page.

I certify that I and/or my dependents incurred these expenses and that the information given is true, correct and complete to the best of my knowledge and that the

attached receipts represent a expense that is medically necessary. I authorize Pacific Employee Benefits, healthcare providers, insurance or reinsurance companies,

administrators of benefits programs, other organizatoins and service providers to exchange personal information, as necessary, for the adjudication of the claims I

submit and the administration of the benefit program. I understand that the personal information will be kept confidential and secure. I have read and understand this

Member consent and Declaration.

Signature of Employee

Date

Oct-13

Extended Health Claim Form Pacific Employee Benefits

Related Articles

Related forms

Related Categories