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HBC OTIP 09/20
For equipment and appliance expenses, OTIP requires a written recommendation from the prescribing physician, including diagnosis, and a copy of the
provincial plan statement of payment (if applicable).
Indicate the activities requiring the use of this item:
SECTION 5: EQUIPMENT AND APPLIANCE EXPENSES
Duration equipment is required - From: To:
Has rental equipment been returned?
Signature of Plan Member Date (mm/dd/yyyy)
SECTION 8: MAILING INSTRUCTIONS
Any Information provided to or collected by the Insurer in accordance with this authorization, will be kept in a beneﬁts health ﬁle.
Access to your Information will be limited to:
The Insurer and their 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.
Date (mm/dd/yyyy) Date (mm/dd/yyyy)
SECTION 6: VISION CARE EXPENSES
Please enclose an itemized receipt indicating: patient’s name, cost of contact lenses, cost of glasses, dispensing fee, cost of eye exam, date of eye exam, cost
of tinting, treatment, and date dispensed.
Medically necessary contact lenses
t Were contact lenses prescribed for severe corneal astigmatism, keratoconus or aphakia? Yes No
t Can visual acuity be improved at least two lines on the Snellen chart over the best possible vision with glasses? Yes No
t Could visual acuity be improved up to the 20/40 level by glasses? Yes No
SECTION 7: CERTIFICATION AND AUTHORIZATION (ORIGINAL RECEIPTS MUST BE ATTACHED FOR ALL EXPENSES)
Total amount of ALL receipts submitted $
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. I authorize OTIP and the group beneﬁts insurance carrier (“Insurer”) that provides my beneﬁts coverage to collect,
use, maintain and disclose personal information relevant to this claim (“Information”) for the purposes of 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, plan administrator, plan sponsor, insurer, investigative agency, and any administrators of other beneﬁts programs to collect, use, maintain and exchange
this Information with each other and with OTIP, the Insurer and their reinsurers and/or service providers, for the Purposes. I authorize the use of my OTIP ID
number for the purposes of identiﬁcation and administration. I agree a photocopy or electronic version of this authorization is valid. I acknowledge that more
Signature of Supplier Date (mm/dd/yyyy)
Please mail your completed claim form and receipts to the address below.
OTIP Health Claims
PO Box 280
Waterloo ON N2J 4A7
OTIP Beneﬁts Services
Receive your claim payments faster with direct deposit and enjoy the
convenience of seeing your claim statements online.
Visit www.otip.com and log in. Once you have logged in to the Plan Member
Secure Site (also known as ‘My Claims’), choose My proﬁle from the top
navigation, then Update banking information. First-time users, you will
need to complete registration.