General Claim Submission Form En - General Claim Submission Page 2
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2GREEN SHIELD CANADA CLAIM SUBMISSION INSTRUCTIONS
Please call our Customer Service Centre at 1-888-711-1119 if you require any assistance in completing this form.
Please ensure that you always provide your Green Shield Canada ID Number in full, including suffix (ie. 00, 01, etc.)
FOR BENEFIT TYPE:
ALWAYS ENCLOSE THE FOLLOWING ITEMS WITH THE ABOVE CLAIM FORM:
● patient name
Audio (Hearing Aids)
Itemized receipts showing
● services & dates
● audiologist name & address
● breakdown of charges (i.e. Acquisition cost, fee, mold)
Prescription Drugs
All itemized prescription drug receipts from your pharmacist
*Please note cash register receipts, credit card receipts and/or debit slips alone are insufficient. Official
pharmacy receipts are required. Please contact your pharmacy for a duplicate copy.
● patient name
Professional Services
Itemized receipts showing
● individual date & nature of treatment
(physiotherapy, chiropractor, massage therapy,
● charge for each service
etc.)
*Some professional services may require a medical referral/physician prescription. Please call Customer Service
at 1-888-711-1119 for details.
● patient name
Durable Medical Equipment
Itemized receipts showing
● a detailed description of the equipment
(including prosthetics or orthotics)
● name & address of supplier
● date & charge for each service
*Some medical equipment may require a medical referral/physician prescription. Please call Customer Service at
1-888-711-1119for details.
Hospital Accommodation
● patient name
Itemized receipts showing
● number of days in semi-private/private accommodation
● rate charged per day
● admission & discharge dates
Vision Care
● patient name
Itemized receipts showing
● copy of vision prescription
● a breakdown of charges for lenses & frames
● date glasses were picked up
Extended Health – General
● patient name
Itemized receipts showing
● a detailed description of services or supplies
● provider's name & address
● date & charge for each service
*Certain types of service or supplies may require a medical referral/physician prescription. Please call Customer
Service at 1-888-711-1119 for details.
Out of Province/Country
Call Customer Service at 1-888-711-1119 for detailed claims submission instructions.
Private Duty Nursing
Call Customer Service at 1-888-711-1119 for detailed claims submission instructions.
*Pre-approval is required for all nursing claims - call Customer Service for details.
General Claim Submission Form EN (2010-11)
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