GENERAL CLAIM SUBMISSION FORM
SECTION 1 - PLAN MEMBER INFORMATION
EMAIL ADDRESS
GREEN SHIELD CANADA ID NUMBER
PHONE NUMBERSURNAME FIRST NAME
COMPANY NAMEADDRESS
POSTAL CODEPROVINCECITY
SECTION 2 - MANDATORY DECLARATION
Do you have any other group insurance coverage that may include these services as benefits? YES NO
If Yes, please provide Insurance company's name ____________________________________________________
If other coverage is with Green Shield Canada, indicate other Green Shield Canada ID number: ___________________________________
Do you want to coordinate this claim with your other Green Shield Canada Coverage? YES NO
Do you want to coordinate this claim with your Health Care Spending Account (if applicable)? YES NO
Is treatment due to a motor vehicle accident? YES NO If yes, Date of Accident (YY/MM/DD) _____________________________
Is treatment required due to a work related injury? YES NO If yes, Date of Injury (YY/MM/DD) _______________________________
If yes, WSIB / WCB Case # ____________________________________
SECTION 3 - CLAIM DETAILS
TOTAL
AMOUNT
CHARGED PER
VISIT/ ITEM
TYPE OF EXPENSE
DATE OF CLAIM
YR MO DAY
PROFESSIONAL/
SUPPLIER'S NAME
and Provider Number (if available)
DATE OF BIRTH
YR MO DAY
DEPENDENT
NO.
(-00, -01, -02)
PATIENT'S NAME
(Only include names of
patients with receipts
attached)
TOTAL CLAIMED
FOR PRESCRIPTION DRUG CLAIMS ONLY:
TO FACILITATE CLAIMS PROCESSING:
• Please note: Cash register receipts, credit card receipts and/or debit slips alone are insufficient. Official pharmacy receipts are required.
• Original receipts must contain patient's name, date of service, Rx number, drug name, quantity dispensed and Drug Identification Number
(DIN)
• If injectable, please provide breakdown of quantity dispensed, drug cost and administration fees.
If claim is from OUT OF COUNTR
Y, please provide:
Name of Country Visited _______________________ Currency Used _________________________ Name of Drug ________________________________
SECTION 4 - AUTHORIZATION
DATESIGNATURE OF PLAN MEMBER
I am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this information
may be seen by the cardholder.
By signing this claim form and/or submitting actual receipts, I agree that the information provided is complete and accurate. I understand that the information
provided by me to Green Shield Canada about myself and my dependents, will be used by Green Shield Canada for claims adjudication and any other services
necessary in the administration of our benefits which may include the exchange of information with other parties to administer this benefit claim.
I further authorize Green Shield Canada to obtain and exchange information with other parties, such as health practitioners or insurers, in order to confirm the
accuracy of the submitted claim(s) information. In the event of suspected fraudulent activity pertaining to claims submitted on behalf of myself and/or my
dependents, I acknowledge and agree to the disclosure of this information to relevant parties, such as the Plan Sponsor, regulatory and law enforcement agencies.
SECTION 5 - MAILING INSTRUCTIONS (See reverse for claim submission instructions)
ALL CLAIMS MUST BE RECEIVED WITHIN 12 MONTHS OF THE DATE OF SERVICE (unless otherwise stated in your benefit plan documentation). PLEASE ATTACH ALL ORIGINAL
DOCUMENTATION and retain copies for your files as original receipts will not be returned. Send your claim to the corresponding address below (be sure to indicate the full address on the
envelope):
OTHER CLAIMSDRUGVISION & ACCOMMODATIONMEDICAL ITEMSPROFESSIONAL SERVICES
P.O. BOX 1606P.O. BOX 1652P.O. BOX 1615P.O. BOX 1623P.O. BOX 1699
WINDSOR, ONWINDSOR, ONWINDSOR, ONWINDSOR, ONWINDSOR, ON
N9A 6W1N9A 7G5N9A 7J3N9A 7B3N9A 7G6
To avoid additional postage costs, please submit multiple claims in one envelope to any of the addresses listed above. When in doubt, choose the "OTHER
CLAIMS" address.
CUSTOMER SERVICE CENTRE 1-888-711-1119 or (519) 739-1133 greenshield.ca
GCLMSGeneral Claim Submission Form EN (2015-02)
