Fillable Printable Extended Health Care Claim Form

Extended Health Care Claim Form

Page 1 of 2The Manufacturers Life Insurance Company GL3585E (05/2007) CII

Group Benefits

Extended Health Care Claim

To be completed by the plan member unless otherwise indicated. Original receipts must be attached for all expenses. (Please attach to the

back of this form.) Please retain copies for your files as original receipts will not be returned.

If employed,

hrs worked

per week

Relationship to

plan member

(1st Claim only)

Date of birth

(dd/mmm/yyyy)

(1st Claim only)

Patient's name

Complete for all expenses.

Use one line per patient.

If "Yes," please retain photocopies of all receipts submitted with this claim for

submission to your secondary carrier. If this is your first claim, or if information

has changed, please provide the following:

Spouse's date of birth

(dd/mmm/yyyy)

1 Plan member information

Are these expenses eligible for coverage under any type

of workers' compensation board?

Are you, your spouse or dependants covered under any other plan for the expenses being claimed?

• Attach your prescription drug receipts to the back of this form.

• All receipts must contain the drug identification number (D.I.N.) and the name of the prescription

drug.

• You are not required to list this information on the form.

Plan member address (number, street and apt.) Postal codeProvinceCity or town

Birthdate (dd/mmm/yyyy)Plan member name (first, middle initial, last)

Plan contract number Plan member certificate number Plan sponsor

School and city

and electronic claim

statements

Receive your claim payments up to 70% faster with direct deposit and enjoy the convenience of seeing

your claim statements online.

Name of spouse's insurance company

Spouse's plan contract number

Spouse's plan member

certificate number

Yes No

• Go to www.manulife.ca/groupbenefits and register for the plan member secure site

• Once you've registered, or if you're already registered, log into the secure site and select

Direct deposit for claims from the menu to the left of the screen

• Enter your banking information

2 Patient information

3 Prescription drug

expenses

(e.g. chiropractor, massage

therapist, physiotherapist, etc.)

4 Practitioner's/

Paramedical expenses

For practitioner/paramedical expenses please attach an itemized statement and/or receipt stating:

• patient name,

• name of practitioner,

• type of practitioner,

• date of service,

• length of visit,

• charge for treatment,

• date last paid by provincial plan (if applicable) and

• licence and/or registration number.

If for psychotherapy, please indicate type (individual, family, group, marriage) on your receipt.

Please complete next page.

• patient's name,

• cost of contact lenses,

• cost of glasses,

• cost of laser surgery,

• dispensing fee,

• cost of eye exam,

• date of eye exam,

• cost of tinting,

• date dispensed.

Page 2 of 2

NOTE - ORIGINAL RECEIPTS

must be attached for all

expenses.

7 Claims confirmation

6 Vision care expenses

To be completed by

supplier.

Please enclose an itemized

receipt indicating:

Please have the supplier complete and sign below.

Were contact lenses prescribed for severe corneal astigmatism,

keratoconus or aphakia?

Can visual acuity be improved by at least 2 lines on the Snellen chart

over the best possible vision with glasses?

Could visual acuity be improved up to at least the 20/40 level by glasses?

8 Mailing instructions

If you live in Quebec:

Manulife Financial Group Benefits

Health Claims

P.O. BOX 2580, STATION B

MONTREAL QC H3B 5C6

Please mail your completed claim form and receipts to the appropriate address.

If you live outside Quebec:

Manulife Financial Group Benefits

Health Claims

P.O. BOX 1653

WATERLOO ON N2J 4W1

The Manufacturers Life Insurance Company GL3585E (05/2007) CII

Indicate the activities requiring the use of this item.

For equipment and appliance expenses Manulife Financial requires a written recommendation from

the prescribing physician, including diagnosis, and a copy of the provincial plan statement of payment

(if applicable).

5 Equipment and appliance

expenses

Duration equipment is required.

Has rental equipment been returned?

ToFrom

Date (dd/mmm/yyyy)Date (dd/mmm/yyyy)

Yes No

Signature of supplier

Date signed (dd/mmm/yyyy)

I certify that I, my spouse and/or my dependants of minor or major age ("Dependants"), have received

all goods or services claimed and that the information provided for this claim is true and complete.

authorize Manulife Financial ("Manulife") to collect, use, maintain and disclose personal information

relevant to this claim ("Information") for the purposes of Group Benefits plan administration, audit and

the assessment, investigation and management of this claim ("Purposes"). I

am authorized by my

Dependants to disclose and receive their Information, for the Purposes. I

authorize any person or

organization with Information, including any medical and health professionals, facilities or providers,

professional regulatory bodies, any employer, group plan administrator, insurer, investigative agency,

and any administrators of other benefits programs to collect, use, maintain and exchange this

information with each other and with Manulife, its reinsurers and/or its service providers, for the

Purposes. I

authorize the use of my Social Insurance Number ("SIN") for the purposes of identification

and administration, if my SIN is used as my plan member certificate number. I

agree a photocopy or

electronic version of this authorization is valid. I

understand that Manulife's Privacy Policy and Privacy

Information Package are available at www.manulife.ca/groupbenefits, or from my Plan Sponsor.

Any Information provided to or collected by Manulife in accordance with this authorization, will be kept

in a Group Benefits health file. Access to your Information will be limited to:

• Manulife employees, representatives, reinsurers, and service providers in the performance

of their jobs;

• Persons to whom you have granted access; and

• Persons authorized by law.

You have the right to request access to the personal information in your file, and, where appropriate, to

have any inaccurate information corrected.

Total amount of ALL receipts submitted

Signature of plan member Date signed (dd/mmm/yyyy)

Please sign here

If your contract covers medically necessary contact lenses, please answer the questions below: