Information Needed to Complete the Form
Your personal Member information and the Group policy number is needed to complete the form. In addition:

• the name of the insured person(s),
• the relationship to the employee,
• birth date(s),
• service provided,
• service date of each claim,
• information about other benefit or insurance plans that you may be eligible to claim from.
• If you are coordinating claim’s payment with your spouse’s health plan, you should include the primary carrier’s payment statement.

Please follow the instructions on the form.

Notes

• These expenses must have been incurred by you or one of the dependents you listed on your enrolment card.
• You must attach all original receipts for reimbursement. These will not be returned. Make a copy for yourself before submitting your claim.
• Don’t send in a claim until your accumulated receipts exceed the deductible for that benefit.
• Submit your claims on a regular basis to avoid delay in processing.

Completed forms should be forwarded to the Plan Administrator.

Frequently Asked Questions

What do I need to send in with the form?

• You must attach all original receipts for reimbursement. These will not be returned. Make a copy for yourself before submitting your claim.
• If you are coordinating claim’s payment with your spouse’s health plan, you must include the primary carrier’s payment statement and a photocopy of the original receipts.

What expenses can I be reimbursed for?

• Eligible expenses are listed in your Health Benefit Plan Booklet.

How does my Assure Drug Card work?

• When you fill a prescription at a pharmacy, your Assure drug card will allow the pharmacy to bill the insurer directly for their share of your prescription drug cost. You will only be required to pay the Member’s portion of the cost at the pharmacy. Since you only pay your share initially, there is no need to submit any claim form. Not all Plans distribute Assure drug cards to their Members.

My spouse is also a Member of a health benefits plan at work, how do I coordinate my claim with my spouse’s benefits plan?

• If a Member or any eligible Dependents are entitled to receive similar benefits simultaneously under your Health Benefit Plan or any other group insurance plan (including Provincial Plans), to prevent over payment, benefits payable under this Plan would be co-ordinated with the other Plan.
• For example: A Member’s wife is covered under her employer’s plan with family coverage. The Member, his spouse and their three children are all covered under both Plans. To determine which plan would be primarily responsible for the dependent children: Between the Member and the spouse, whomever’s birthday falls first in the calendar year, their plan is responsible for the initial reimbursement of benefits for the dependent children, then, any amounts that are not paid by that Plan are submitted to the other parent’s plan.
• In the event that the Member’s birthday is in April and the spouse’s birthday is in January. The spouse’s plan would be primarily responsible for the spouse’s claims and the claims of the children. Any amounts not paid by the spouse’s plan can be submitted to the Member’s Plan for reimbursement. Any amounts for the Member that are not paid by the Member’s Plan can be submitted to the spouse’s plan for reimbursement.

Other questions on completing the form should be directed to the Plan Administrator.