Fillable General Claim Submission Form En - General Claim Submission printable pdf download

GENERAL CLAIM SUBMISSION FORM

SECTION 1 – PLAN MEMBER INFORMATION

GREEN SHIELD CANADA ID NUMBER

EMAIL ADDRESS

SURNAME

FIRST NAME

PHONE NUMBER

ADDRESS

COMPANY NAME

CITY

PROVINCE

POSTAL CODE

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?

YES

If yes, Date of Injury (YY/MM/DD) ________________________________________

Is treatment required due to a work related injury?

YES

If yes, WSIB Case # ________________________________________

SECTION 3 – CLAIM DETAILS

TOTAL

DATE OF CLAIM

DATE OF BIRTH

PATIENT’S NAME

DEP

PROFESSIONAL/

AMOUNT

TYPE OF EXPENSE

(Only include names of patients with receipts

NO.

SUPPLIER’S NAME

CHARGED PER

attached)

DAY

and Provider Number (if available)

VISIT/ ITEM

TOTAL CLAIMED

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

required.



Original receipts must contain patient’s name, date of service, Rx number, drug name, quantity dispensed and Drug Identification

Number (DIN)



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

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 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:

PROFESSIONAL SERVICES

MEDICAL ITEMS

VISION & ACCOMMODATION

DRUG

OTHER CLAIMS