HEALTH SPENDING ACCOUNT
CLAIM SUBMISSION FORM
This form should be used when claiming reimbursement under your Health Spending Account, Health Care Expense Account or
Health Services Spending Account for eligible expenses which are not covered (or not covered in full) by your Health or Dental
Plan.
Date of Birth
Alternate I.D. # Plan Member ID
/ /
YY MM DD
First NameSurname
Telephone No. ( )
Mailing Address
Postal Code Province City
Do you have any other Group Insurance coverage that may include these services as benefits? Yes No
If yes, please provide Insurance Company name
If other coverage is RBC Life, indicate Plan Member ID
Be sure you have first submitted these claims to any provincial health insurance, or any private health care plan you may have (including another
RBC Life plan, spousal plan, etc.)
I want my eligible expenses paid from my RBC Life health plan or dental plan first and any unpaid portions of my eligible expenses paid from
my HSA
I want all my eligible expenses paid from my RBC Life health plan or dental plan first, then any unpaid portions of my eligible expenses paid
from my other RBC Life #_____________________ and if still unpaid portion remaining, paid under my HSA.
I want all my eligible expenses paid directly from my HSA.
NOTE: If no box has been checked, we will pay claims according to Box 1.
HEALTH CARE EXPENSES (Please include receipts, prescriptions, etc.)
AmountDependent #NameDate of ExpenseDescription of Expense
$Total Amount Claimed
Subject to the limitations of Revenue Canada and the rules and
regulations of the plan, I hereby authorize RBC Life to charge the
above claim to my Health Spending Account.
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 RBC Life about myself and
my dependents, will be used by RBC Life 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 RBC Life 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.
Signature of Plan Member Date
Mail this form and enclosures to: RBC Life Insurance Company
Attention: Health Spending Account
PLEASE INDICATE ON MAILING ENVELOPE
Professional Services, P.O. Box 1613, Windsor, ON N9A 0B8 Drug Dept. P.O. Box 1602, Windsor, ON N9A 0B5
Other Claims, P.O. Box 1601, Windsor, ON N9A 0B4 Medical Items, P.O. Box 1610, Windsor, ON N9A 0B7
Dental Dept. P.O. Box 1614, Windsor, ON N9A 0B9 Vision/Hospital Dept. P.O. Box 1603, Windsor, ON N9A 0B6
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.
For inquiries contact:
CUSTOMER SERVICE CENTRE Toll Free 1-855-264-2174
The cost, if any, of obtaining this information is at the expense of the Patient/Plan Member.
RBC - Claim Form for HCSA EN (2018-12) HCSA
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signature
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