Fillable Claim Form For Custom Foot Orthotics printable pdf download

P.O. Box 1623

WINDSOR, ON N9A 7B3

Attention: EHS Department

Customer Service Centre 1-888-711-1119 or (519) 739-1133

CLAIM FORM FOR CUSTOM FOOT ORTHOTICS

To the Patient:

The details requested below are mandatory in order for Green Shield to determine our liability with respect to this request.

PROVIDER

PATIENT

Provider No.

Telephone No.

Green Shield I.D. No.

Date of Birth

(

)

_______/_______/_______

Name

Street Address

Address

City

Province

Postal Code

City

Province

Postal Code

Do you have any other Group Insurance coverage that may include these services as benefits?

Yes

If yes, please provide Insurance Company name ______________________________________________________________________

If other coverage is Green Shield, indicate Green Shield number __________________________________

THIS SECTION MUST BE COMPLETED IN FULL BY THE DISPENSING AND/OR TREATING PHYSICIAN / CHIROPODIST /

PODIATRIST / PROFESSIONAL.

1. I hereby prescribe/provide the following for the above named patient (Please include specifications):

_________________________________________________________________________________________________________

2. Diagnosis (please be specific): ________________________________________________________________________________

_________________________________________________________________________________________________________

3. Please identify which diagnostic measures were included in the determination of need:

__________ Biomechanical Examination

__________ Bone Position Measurements __________ Stance and Gait Analysis

Other _________________________________________________________________________________________________



Please include copy of applicable test results.

4. Please describe previously attempted alternate therapies: ________________________________________________________

_______________________________________________________________________________________________________

Is the device(s) and/or medical equipment required:

as a result of a work related injury? Yes

as a result of a motor vehicle accident: Yes

for sports purposes only? Yes

______________________________________________________________

Date __________________________________________________

Name of Physician / Chiropodist / Podiatrist (Please Print)

Signature ____________________________________________________

Phone No. _(_______)____________________________________

TREATMENT DESCRIPTION

DATE OF PICKUP

CHARGES $

DAY

I CERTIFY THAT THE TREATMENT DESCRIBED ABOVE WAS PERFORMED BY ME AND ALL INFORMATION PROVIDED ON THIS FORM IS ACCURATE.

________________________________________

___________________________________

Signature of Provider

Accreditation

Registered No.

THE SUBSCRIBER HAS PAID THE CHARGES LISTED ON THIS

I certify that the orthotics have been picked up and are in my possession and hereby

CLAIM

FULL.

PLEASE

REIMBURSE

SUBSCRIBER

authorize payment directly to the provider named above.

DIRECTLY.

Signature of Provider

Signature of Patient

Date

By signing this claim form and/or submitting actual receipts, I agree that the information provided on this form is complete and accurate. I understand that the information provided

by me to Green Shield Canada about myself and my dependants, will be used by Green Shield Canada for claims adjudication and any other services necessary in the administration of

our benefits which may include the exchange of information with other parties to administer this benefit claim.

I am authorized by my spouse and/or dependants to disclose and receive information about them that is used for these purposes. I understand that this information may be seen by the

cardholder.

THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/SUBSCRIBER.

ALL CLAIMS MUST BE SUBMITTED WITHIN 12 MONTHS OF THE DATE OF SERVICE.

CFO

Claim Form for Custom Foot Orthotics EN (Rev. 2010-12)