Day Year
Day Month Year
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Any modification of this document without the express written consent of Canada Life is strictly prohibited.
Healthcare Expenses Statement
With Healthcare Spending Account
1. Complete page 1 and 2 of this form in full.
2. Sign and date the form.
3. Please retain copies for your files as original receipts will not be returned.
4. Send to the appr opriate Benefit Payment Office for your plan.
See PART 9.
Benefits to be paid from:
Healthcare Plan Only
Healthcare Spending Account Only
All claims under this group benefits plan are submitted through
the plan member. We may exchange personal information about
claims with the plan member and a person acting on their behalf
when necessary to confirm eligibility and to mutually manage
the claims.
PART 1 - Plan Member Information
You must
complete this
section fully.
If you are
unsure of your
plan name, plan
number or
plan member
I.D. number,
please contact
your plan
Plan Member Name
Plan Member Address
Language preference:
English French
PART 2 - Coordination of benefits
Complete this
section to
indicate whether
you or any
member of your
family have
coverage from
any other plan.
1. Are you, or any member of your family, entitled to benefits under any other plan for the expenses
being claimed? Yes No If yes, please provide:
2. Is treatment required as the result of a
motor vehicle accident?
Yes No
3. Is a claim being made for Workers’
Compensation Benefits?
Yes No
PART 3 - Patient information
Complete for all
expenses; one
line per patient.
Patient name Relationship to
plan member
Date of birth
Day Month Year
If child over 18 years
Does Patient
Reside with Plan
Yes No
Full time
Yes No
If employed,
how many
hours worked
per week?
PART 4 - Prescription drug expenses
For all prescription
drug claims
Attach all original receipts.
Patient name, date of purchase, drug identification number and drug name.
Plan name
Plan number Plan member I.D. number
Last name First name
Number and street
City or town Province Postal code
Day Month Year
Date of birth:
Name of insurance company
Plan number
Plan member I.D. number
If spouse's plan, please provide spouse's date of birth:
DayDay MonthMonthMonth Year
PART 5 - Paramedical Expenses
For chiropractor,
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
appliances and
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
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
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
Day Month Year
Plan Member signature X