CLAIM FORMS

CLAIM FORMS2018-10-30T18:35:30+00:00

Project Description

To find the form that you need, click on the appropriate carrier company below, and click on the link to the form you need. It will open as a fillable PDF, or you can download and fill it out.

ENROLMENT FORM
Complete this form to authorize benefit coverage for new employees.

Change Form
This form should be used for any changes to a employee record such as Beneficiary or Trustee updates, addition/deletion of dependents, address updates etc.

Medical Expenses Claim Form – English
Medical Expenses Claim Form – French
Use this form to obtain a reimbursement under your Extended Health Care benefit for eligible medical expenses such as prescription drugs, paramedical practitioners, hospital room accommodation, vision care, etc. (Actual benefits covered are detailed in your employee handbook.)

Medical Expenses/HSA Claim Form – English
Use this form to obtain a reimbursement under your Health Spending Account for eligible medical and/or dental expenses.

For all other claim forms please contact your plan administrator.

Medical Expenses Claim Form
Use this form to obtain a reimbursement under your Extended Health Care benefit for eligible medical expenses such as prescription drugs, paramedical practitioners, hospital room accommodation, vision care, etc.

Dental Care Claim Form
Most dentists provide plan members with a standard Canadian Dental Association (CDA) claim form. If the dentist does not provide a CDA form, use this form to obtain a reimbursement under your Dental Care benefit for eligible dental expenses.

Foot Orthotics Claim Guide
This guide provides an explanation of the information you are required to submit for foot orthotics claims.

Orthopedic Shoe Claim Guide
This guide provides information on claiming for orthopedic shoes.

Dental Care In Case Of An Accident
For reimbursement of dental care when the expenses are incurred following an accident. This care is reimbursable under the health insurance coverage. This claim form is to be used only if you have sustained an accidental injury to your natural teeth.

Health Spending Account Claim Form
Use this form to obtain a reimbursement under your Health Spending Account for eligible medical and/or dental expenses.

Important Notice: If you or your eligible dependents have incurred an emergency medical or dental expense while outside of Canada, you must call the Medical Assistance Service Provider, CanAssistance, at one of the numbers listed below. They will provide you with the claim form(s) you require.

For all other claim forms please contact your plan administrator.

Toll Free: 1-800-203-9024 or 514-499-3747 (call collect)

Medical Expenses Claim Form
Use this form to obtain a reimbursement under your Extended Health Care benefit for eligible medical expenses such as prescription drugs, paramedical practitioners, hospital room accommodation, vision care, etc.

Dental Care Claim Form
Most dentists provide plan members with a standard Canadian Dental Association (CDA) claim form. If the dentist does not provide a CDA form, use this form to obtain a reimbursement under your Dental Care benefit for eligible dental expenses.

Medical Expenses / HCSA Claim Form
Use this form to obtain a reimbursement for eligible medical expenses under both your Extended Health Care benefit and your Health Care Spending Account, all on one form.

Dental Care / HCSA Claim Form
Use this form to obtain a reimbursement for eligible dental expenses under both your Dental Care benefit and your Health Care Spending Account, all on one form.

Out-Of-Country Claim Form
Use this form to obtain a reimbursement for eligible emergency medical expenses incurred while outside your province of residence, for physician’s fees and hospital services.

For all other claim forms please contact your plan administrator.

Medical Expenses Claim Form
Use this form to obtain a reimbursement under your Extended Health Care benefit for eligible medical expenses such as prescription drugs, paramedical practitioners, hospital room accommodation, vision care, etc.

Dental Care Claim Form
Most dentists provide plan members with a standard Canadian Dental Association (CDA) claim form. If the dentist does not provide a CDA form, use this form to obtain a reimbursement under your Dental Care benefit for eligible dental expenses.

Foot Orthotics Claims
This checklist provides an explanation of the information you are required to submit for foot orthotics claims.

Orthopedic Shoe Claim Checklist
This checklist provides information on claiming for orthopedic shoes.

Health Spending Account Claim Form
Use this form to obtain a reimbursement under your Health Spending Account for eligible medical and/or dental expenses.

Pacific Blue Cross Emergency Out-Of-Province Claim Form
Use this form to obtain a reimbursement for eligible emergency medical expenses incurred while outside your province of residence.

For all other claim forms please contact your plan administrator.

Contact Info

Suite 200, 2626 Croydon Drive
Surrey, BC V3Z 0S8

Phone: 1.877.542.4110