GENERAL CLAIM SUBMISSION FORM
SECTION 1 – PLAN MEMBER INFORMATION
GREEN SHIELD CANADA ID NUMBER
SECTION 2 - MANDATORY DECLARATION
Do you have any other group insurance coverage that may include these services as benefits? YES
If Yes, please provide Insurance company’s name ____________________________________________________
If other coverage is Green Shield Canada, indicate Green Shield Canada ID number: _____________________________________
If yes, Date of Accident (YY/MM/DD) _____________________________________
Is treatment due to a motor vehicle accident?
If yes, Date of Injury (YY/MM/DD) ________________________________________
Is treatment required due to a work related injury?
If yes, WSIB Case # ________________________________________
SECTION 3 – CLAIM DETAILS
DATE OF CLAIM
DATE OF BIRTH
TYPE OF EXPENSE
(Only include names of patients with receipts
and Provider Number (if available)
FOR PRESCRIPTION DRUG CLAIMS ONLY:
TO FACILITATE CLAIMS PROCESSING:
Please note: Cash register receipts, credit card receipts and/or debit slips alone are insufficient. Official pharmacy receipts are
Original receipts must contain patient’s name, date of service, Rx number, drug name, quantity dispensed and Drug Identification
If injectable, please contact Green Shield Canada for specific claim requirements.
If claim is from OUT OF COUNTRY, please provide:
Name of Country Visited ___________________________ Currency Used __________________________ Name of Drug ___________________________________
SECTION 4 - AUTHORIZATION
SIGNATURE OF PLAN MEMBER
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 dependents, 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 dependents to disclose and receive information about them that is used for these purposes. I understand that this information
may be seen by the cardholder.
SECTION 5 – MAILING INSTRUCTIONS
laim submission instructions)
(See reverse for c
PLEASE ATTACH ALL ORIGINAL CORRESPONDENCE and retain copies for your files as original receipts will not be returned.
ALL CLAIMS MUST BE SUBMITTED WITHIN 12 MONTHS OF THE DATE OF SERVICE
PLEASE INDICATE ON MAILING ENVELOPE:
VISION & ACCOMMODATION
P.O. BOX 1699
P.O. BOX 1623
P.O. BOX 1615
P.O. BOX 1652
P.O. BOX 1606
GREEN SHIELD CANADA
CUSTOMER SERVICE CENTRE
1-888-711-1119 or (519) 739-1133
General Claim Submission Form EN (2010-11)