Fillable Printable Public Service Health Care Plan (PSHCP) Claim Form
Fillable Printable Public Service Health Care Plan (PSHCP) Claim Form
Public Service Health Care Plan (PSHCP) Claim Form
Page 1 of 2
EHC-55555-E-09-10 (G3589-E)
Public Service Health Care Plan (PSHCP)
Claim Form
PROTECTED once completed. Ce formulaire est disponible en français.
Please read all instructions and information; make sure that all sections are complete and accurate
or this claim will be returned to you.
For HO use only:
HCF
Contract number
055555
1
I
Memberinformation
Last nameFirst nameCertificate number
Date of birth (yyyy-mm-dd)
– –
Language preference
English
French
Gender
Male
Female
Home telephone number
– –
Permanent address (street number and name)Apartment or suite
CityProvince/territoryPostal code
Your claim will be adjudicated
based on the coordination
of benefits information you
provided about yourself and
your eligible dependants
during positive enrolment.
Any discrepancies could result
in a delay in payment.
If your spouse is a member of
another group health care
plan, he/she must submit
his/her expenses under that
plan first.
2
I
Coordinationofbenefits
Is your spouse a member of the PSHCP or another plan administered by
Sun Life Financial?
Yes
No If yes, provide details below.
Does your spouse authorize us to process this claim under his/her
certificate number?
Yes
No If yes, provide details below.
Last name of spouseGender
Male
Female
Spouse’s contract numberSpouse’s certificate number
Signature of spouse
X
3
I
Completeifclaimingexpensesforyourspouseordependantchildren
First nameLast nameDate of birth (yyyy-mm-dd)Relationship to you
– –
Spouse
Daughter
Son
Other
– –
Spouse
Daughter
Son
Other
– –
Spouse
Daughter
Son
Other
– –
Spouse
Daughter
Son
Other
Ensure that the currency and
amount are clearly marked
on each receipt. We will
convert the eligible expenses
to Canadian dollars.
Attach original receipts for
each expense claimed.
4
I
Informationaboutyourclaim
Are any of the expenses the result of a work injury?
Yes
No
If yes, enclose your worker’s compensation statement.
Are any of the expenses the result of a motor vehicle accident?
Yes
No
If yes, enclose your automobile insurance plan statement.
Are any of the expenses incurred outside your province/territory of residence?
Yes
No
If yes, provide the date of departure from your home province/territory
Date (yyyy-mm-dd)
– –
Were you on government business travel?
Yes
No
Total amount submitted for this claim
$
For HO use only:
HCF
Page 2 of 2
EHC-55555-E-09-10 (G3589-E)
To print a new claim form, or use the online version, visit
www.pshcp.ca
or
www.sunlife.ca/pshcp
.
Interested in receiving your payment via direct deposit?
Want to know the status of your claim?
Other questions?
5
I
Authorizationandsignature
By signing below, I certify that all goods and/or services being claimed have been received by me, my
spouse or my eligible dependant children. I certify that, to the best of my knowledge, the information
in this form is true and complete and does not contain a claim for any expense previously paid for by
this or any other plan. I also certify that all claimants on this form continue to meet the plan eligibility
requirements. I acknowledge and agree that the terms of my Positive Enrolment “Consent to release of
personal information” apply to this claim.
I hereby authorize Sun Life, its agents and service providers to collect, use and disclose information
about me, my spouse and my dependants to other persons and organizations including health
professionals who have, or require, relevant personal information about me, my spouse and my
dependants pertaining to this claim for the purposes of administration, audit, paying claims and
patient safety.
Member signature
X
Date (yyyy-mm-dd)
– –
Keeping your information confidential
At all times, the information collected will be protected under the provisions of thePersonal Information
Protection and Electronic Documents Act (PIPEDA).
Mailinginstructions
–
keep a copy of this form for your records
Keep a copy of your
claim form and
receipts for your
records, since
Sun Life will not
return the originals.
Sun Life Assurance Company of Canada
PO Box 9601, CSC-T
Ottawa ON K1G 6A1
For assistance call the Sun Life PSHCP call centre at (613) 247-5100 / 1-888-757-7427
Monday to Friday, 6:30 a.m. to 8:00 p.m. EST
Definition of spouse:
A spouse means the
person who is legally
married to the member,
or a person with whom
the member has lived
for a continuous period
of at least one year,
whom the member has
publicly represented
to be their spouse and
continues to live with
as if that person were
their spouse, as desig-
nated by the member.
For HO use only:
HCF
Page 2 of 2
EHC-55555-E-09-10 (G3589-E)
To print a new claim form, or use the online version, visit
www.pshcp.ca
or
www.sunlife.ca/pshcp
.
Interested in receiving your payment via direct deposit?
Want to know the status of your claim?
Other questions?
5
I
Authorizationandsignature
By signing below, I certify that all goods and/or services being claimed have been received by me, my
spouse or my eligible dependant children. I certify that, to the best of my knowledge, the information
in this form is true and complete and does not contain a claim for any expense previously paid for by
this or any other plan. I also certify that all claimants on this form continue to meet the plan eligibility
requirements. I acknowledge and agree that the terms of my Positive Enrolment “Consent to release of
personal information” apply to this claim.
I hereby authorize Sun Life, its agents and service providers to collect, use and disclose information
about me, my spouse and my dependants to other persons and organizations including health
professionals who have, or require, relevant personal information about me, my spouse and my
dependants pertaining to this claim for the purposes of administration, audit, paying claims and
patient safety.
Member signature
X
Date (yyyy-mm-dd)
– –
Keeping your information confidential
At all times, the information collected will be protected under the provisions of thePersonal Information
Protection and Electronic Documents Act (PIPEDA).
Mailinginstructions
–
keep a copy of this form for your records
Keep a copy of your
claim form and
receipts for your
records, since
Sun Life will not
return the originals.
Sun Life Assurance Company of Canada
PO Box 9601, CSC-T
Ottawa ON K1G 6A1
For assistance call the Sun Life PSHCP call centre at (613) 247-5100 / 1-888-757-7427
Monday to Friday, 6:30 a.m. to 8:00 p.m. EST
Definition of spouse:
A spouse means the
person who is legally
married to the member,
or a person with whom
the member has lived
for a continuous period
of at least one year,
whom the member has
publicly represented
to be their spouse and
continues to live with
as if that person were
their spouse, as desig-
nated by the member.
