PART 5 - Paramedical Expenses
For chiropractor,
physiotherapist,
massage
therapist,
psychologist, etc.
Attach original receipts. Receipts must indicate the:
• Patient name, length and type of service and date of service
• Healthcare provider’s name, address, phone number, designation and professional association
• Date last paid by provincial plan (if applicable)
Provider's name Type of service Phone number
PART 6 - Medical Expenses
For medical
equipment,
appliances and
services.
Attach original receipts and recommendation from prescribing physician, including diagnosis.
Receipts must indicate the:
• Patient name, date of service and description of item purchased
• Provider's name, address and telephone number
• Provincial plan statement of payment (if applicable)
PART 7 - Visioncare Expenses
Laser eye
surgery, glasses,
contact lenses
and eye exams.
Attach original receipts.
Reason for purchase of lenses? (check all that apply)
Initial prescription Prescription change Loss or breakage
None of the above
PART 8 - Confirmation, Authorization and Signature
I certify that the information given on this claim form is true, correct and complete to the best of my knowledge. I certify that all goods and services being claimed have
been received by me, my spouse and/or my dependents; and that my spouse and/or dependents are eligible under the terms of my plan.
I certify that I am claiming expenses that were incurred by myself or a person(s) for whom I am entitled to claim a medical expense credit under the Income Tax Act (Canada).
The submission of fraudulent claims is a criminal offence. Canada Life takes the submission of fraudulent claims seriously. Suspected fraudulent claims may be reported to
your employer or plan sponsor and to the appropriate law enforcement agency.
At Canada Life, we recognize and respect the importance of privacy. Personal information that we collect will be used for the purposes of assessing your claim and
administering the group benefi ts plan. I authorize Canada Life, any healthcare or dentalcare provider, my plan administrator, other insurance or reinsurance companies,
administrators of government benefi ts or other benefi ts programs, other organizations or service providers working with Canada Life located within or outside Canada, to
exchange personal information when necessary for these purposes. I understand that personal information may be subject to disclosure to those authorized under
applicable law within or outside Canada.
I also consent to the use of my personal information for Canada Life and its affi liates’ internal data management and analytics purposes.
For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect to service providers), write to
Canada Life’s Chief Compliance Officer or refer to www.canadalife.com.
PART 9 - Submitting Your Claim
Please send your claim to the Benefit Payment Office below. If blank, please consult your plan administrator for the address.
Questions? Call Toll Free: 1.800.957.9777
Winnipeg Benefit Payments
PO Box 3050 Station Main
Winnipeg MB R3C 0E6
www.canadalife.com
Deaf or hard of hearing and require access to a telecommunications relay service?
Please contact us:
TTY to Voice: 711
Voice to TTY: 1-800-855-0511
Continued (page 2 of 2)
Canada Life
Healthcare Expenses Statement
5
6
7
• • •
•
8
Day Month Year
Plan Member signature X
Date:
9
M635D(HCSA-W)-3/20
Page 2 of 2 YOU MUST COMPLETE BOTH PAGES
