BENEFIT TYPE: PLEASE ENCLOSE THE FOLLOWING ITEMS WITH THE ABOVE CLAIM FORM: Prescription Drugs All itemized Prescription drug receipts from your pharm...
T2491 v.03 11.06.2017. Page . 1. of . 8. 01-CA9674 H. SETTLEMENT REGISTRATION/CLAIM FORM. Auto Airbag Settlement for
Denplan Corporate claim form To help us settle your claim quickly please complete all sections as accurately as you can. ... Denplan Corporate, Denplan Ltd,
SUBSCRIBER INFORMATION Primary Participant ID# (required) Company Employee Number (if appropriate) Plan Sponsor Last Name First Name Middle Initial
OTHER COVERAGE. Statement of Actual Services – OR –. Request for Predetermination / Preauthorization ... 40. Is Treatment for Orthodontics? Provider's Office. Hospital. ECF. Other. 45. Treatment Resulting from (Check applicable box). 47. Auto Acciden
Payee NRIC: Bank Account No:: Notification of payment will be sent to this email address. Important Notice: The Company shall (i) be discharged from all liability
BROKER INFORMATION. BORROWER INFORMATION PROPERTY INFORMATION. Loan Submission Form - Government Programs. FHA SPONSOR NUMBER: 24751-0000-5. VA SPONSOR NUMBER: 902324
Please use one claim form per person Payment Denplan for Schools Claim Form ... the claim form must be signed by the ... Email: [email protected] Registered in
Denplan claim form To help us settle ... Denplan Corporate, Denplan Court, ... please make sure this is clearly stated on this claim form and your itemised receipt
Aetna International Claim Form . Please submit this completed claim form with itemized bills and receipts. A separate claim form is needed for each family
CITY OF PHILADELPHIA. RISK MANAGEMENT DIVISION - CLAIMS UNIT. 1515 ARCH STREET ... DATE OF BIRTH: SOCIAL SECURITY NUMBER: DATE AND TIME OF THE ACCIDENT/INCIDENT: ... THE CITY WILL PROVIDE AN AFFIDAVIT OF NO INSURANCE TO BE NOTARIZED. AFTER SUBMITTING
Zurich Australian Insurance Limited ABN 13 000 296 640, AFS Licence No. 232507. 5 Blue Street North Sydney NSW 2060. General Claim Form – Page 1 of 4. General. Claim form. ZU07392 - V3 03/14 - CW. AN-006478-2012. All relevant sections are to be answe
or your tenant, or related to you, give full details werknemer, ‘n huurder of ‘n familielied is, meld besonderhede Claim If a claim has been, or is being
Download GLOBE GADGET CARE. CLAIM FORM. Important Information. 1. In order to submit your claim, please complete the relevant sections. This first page must be ...
Date of birth DDDDDDDD . Dental claim form . Bu Please ensure that you complete this form fully and return it to us with copies or uploads of your original receipts
National Health Insurance Company – Daman ... Reimbursement Claim Form ... healthcare services provided to me during the period of my insurance coverage with Daman
PLEASE READ BEFORE COMPLETING THE CLAIM FORM ‘ All claim forms should be submitted ... completed this form please post it to: Denplan Corporate Denplan Court
Income Details of Claimant PPS No. Please enter details of income that was subject to PAYE in the year of claim. These details are available on your Form P60 or, if
INSURANCE COVERAGE. In order that subrogation claims may be adjudicated, it is essential that the claimant provide the following information regarding the insurance
FORM 1 CLAIM FOR COMPENSATION AND MEDICAL REPORT (Sections 17(1) and 24(1)(a) of Act No. 56 of 1996 and regulation 3(1) of the Regulations under the Act.)
APPROVED OMB-0938-1197 FORM 1500 (02-12) 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
3. AUTHORITY – Provide details regarding your authority to complete a claim for the missing bonds. YesAre you named on the bonds? NoIf , skip to Item 4
If you received a service in: Return your form to: Alabama Cahaba GBA Medicare Part B Claims P.O. Box 6169 Indianapolis, IN 46206 Alaska Noridian Healthcare Solutions
MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM ... If you are a member of a group plan that ... Complete and sign the Medical Expense Reimbursement Account Claim form
Pages 2-5 - Accident Medical Expense Claim Form Pages 6-8 ... ZURICH AMERICAN INSURANCE COMPANY PROOF OF CLAIM – ACCIDENT MEDICAL EXPENSE
CLAIM SUBMISSION FORM Mail to: P.O. Box 1606, Windsor ON N9A 7G6 CUSTOMER SERVICE CENTRE 1-888-711-1119 Do you have any other group insurance coverage that may include the claim as a benefit?
P la n M e m b e r L a s t N a m e
Yes
First Name
No
If yes, please indicate name of other insuring agency: C o m p a ny N a m e Green Shield Canada ID#
Dep #
Year
Patient’s First Name
Birth Date Month Day
If other coverage is Green Shield Canada indicate the Green Shield Canada ID Card #:
Submit copies of other carrier’s statement along with corresponding receipts. Address
City
Postal Code
Are any of the enclosed claims due to: Province
Telephone
Country
1. A work related injury
Yes
No
2. A Motor Vehicle Accident
Yes
No
If “Yes” please indicate the date of the accident (loss):
Plan Member Signature PLEASE INCLUDE ORIGINAL PAID RECEIPTS For claim submission instructions, please see reverse.
By signing this form and/or submitting actual receipts, I agree that the information provided is complete and accurate, to the best of my knowledge. I authorize Green Shield Canada to exchange information with other parties as required and only when the information is needed to administer this benefit claim and/or confirm the accuracy of this information.
CLAIM SUBMISSION INSTRUCTIONS Please ensure that you provide your Green Shield Canada ID Card # including suffix (i.e. 00, 01, etc.)
BENEFIT TYPE:
PLEASE ENCLOSE THE FOLLOWING ITEMS WITH THE ABOVE CLAIM FORM:
Prescription Drugs
All itemized Prescription drug receipts from your pharmacist Please note cash register receipts or credit card receipts alone are unacceptable
Professional Services (Physiotherapy, Chiropractor, etc.)
Itemized receipts showing
Durable Medical Equipment (including prosthetics or orthotics)
Itemized receipts showing
Hospital Accomodation
Itemized receipts showing
Vision Care
Itemized receipts showing
Extended Health - General
Itemized receipts showing
Dental
• •
• • •
patient name individual date & nature of treatment date & charge for each service
• patient name • a detailed description of the equipment • name & address of supplier • date & charge for each service Some medical equipment may require Physician’s approval - call Green Shield Canada for details • • • • • • • •
patient name number of days in semi-private/private accomodation rate charged per day admission & discharge dates patient name a detailed description of services or supplies provider’s name & address date & charge for each service
• patient name • a detailed description of services or supplies • provider’s name & address • date & charge for each service Medical referral may be required for certain types of services and supplies
•
Please send in a “Standard Dental Claim Form” obtained from your dental office. If your dental office gives you a receipt instead, submit it along with a claim form including all the information about the dental services that were performed. For Orthodontic claims a copy of the Orthodontic contract/treatment plan is required with the first Orthodontic claim. Green Shield does not reimburse for Orthodontic treatments paid in advance for services not yet provided.
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
Hearing Aids
Itemized receipts showing
Claim Submission Form EN (Rev. 2010-04)
• • • •
patient name services & dates audiologist name & address breakdown of charges (i.e. Acquisition cost, fee, mold)
