Claim And Authorization Form printable pdf download

CLAIM AND AUTHORIZATION FORM

CLAIM #

PATIENT INFORMATION - MEDICAL

Last Name:

First Name:

Date of Birth:

Address:

City:

Province:

Postal Code:

Home Phone:

Mobile Phone:

E-mail Address:

‘You’ or ‘Your’ refers to the primary insured named on this claim form. If the Primary insured is a minor, the parent or legal guardian is referred to as ‘You’ or Your’

Please confirm your preferred primary method of contact (select one):

Home Phone

Mobile Phone

If you selected ‘Home Phone’ or ‘Mobile Phone’; please advise the best time/day to be reached between Monday – Friday 8AM – 5PM EST

Enter Time: _______ AM/PM ; Circle Day: Monday Tuesday Wednesday Thursday Friday

(by selecting your preferred method of contact, you are providing consent for «ltw_text_3» to discuss your claim information via phone or email)

CANADIAN FAMILY DOCTOR AND/OR SPECIALIST INFORMATION

Your medical history may be required to fully review your claim. Please provide your Canadian physician(s) information below.

Family Physician(s):

Telephone:

Walk-in Clinic (if applicable):

Telephone:

Canadian Specialist(s):

Telephone:

CLAIM DETAILS

1. Trip Departure Date: _____________________

Trip Return Date: _______________________

2. The date you sought medical attention: ____________________________

3. The reason for seeking medical attention (diagnosis): ____________________________________________________________________

4. If you incurred eligible expenses and your claim is payable, please provide name and address of whom the claim should be paid out to:

Name:

Address:

OTHER INSURANCE INFORMATION

1. Please enter your Provincial Health Insurance Plan number below:

Provincial Health Insurance Plan Card #: ________________________

Version Code: ________ (Ontario Only) Some Ontario residents have 1 or 2 Alpha letter(s) added at the end of their OHIP

Card #

2. Are you, or your spouse, entitled to benefits under any other plan for the medical expenses being claimed?

YES

If YES, please provide details below; if NO, leave blank and complete the next section;

You

Your spouse

Name of Insurance Company:

Plan Number:

Plan member ID number:

If spouse’s plan, please provide spouse’s name: _________________________________ and date of birth: ____/____/________ (DD/MM/YYYY)

3. Do you have a Credit Card?

YES

If YES, please provide details below:

To help you receive all additional payments you are entitled to, we will coordinate with any other potential insurers on your behalf. We will determine if

the card provides coverage for your incident.

Credit Card Number:

Type of Credit Card:

PLEASE CONFIRM BOTH SIDES OF THE CLAIM FORM ARE COMPLETED