9 Vision care
10 Email address
11 Claims
confirmation
12 Authorization and consent
Total amount of all
receipts submitted:
$
Note: You must include the original
receipts for all expenses
Make sure you attach an itemized statement or receipt that includes:
By providing your email address, you will receive an email notification once your claim has been received and processed, including a link
to manulife.ca/secureserve where you sign up for direct deposit, online claims, and view your benefit details.
• patient name
• cost of contact lenses
• cost of glasses
• date of eye exam
• cost of tinting
• date dispensed
• date last paid by Government Health
Insurance Plan (GHIP) or GHIP plan
maximum reached (if applicable)
• cost of laser surgery
• dispensing fee
• cost of eye exam
Please Sign here - Your claim will not be processed without your original signature. Digital signature is not valid.
Signature of insured Date signed (dd/mmm/yyyy)
By submitting a claim to Manulife, I confirm that I understand and agree to all of the following:
I certify that the information provided for the claim(s) being submitted is true, accurate, and complete and that I, my spouse or co-applicant and/or my dependents
have received all goods or services or qualify for benefits as claimed. I understand and acknowledge that submission of a claim determined by Manulife to be false
or misrepresented may result in coverage being rescinded by Manulife without further notice. I understand and acknowledge that Manulife may refer any claims
it has determined were falsely submitted to law enforcement authorities for possible prosecution and may pursue the recovery of any money obtained improperly
through false claim submission. I also agree to refund any monies or overpayments that I may owe to Manulife in accordance with the provisions of my coverage
and I authorize Manulife to deduct such monies from my future claims. I authorize any person or organization with information about me or my family members
to collect, use, maintain, and exchange this information with each other and with Manulife or Manulife’s service providers to administer my plan, audit or assess my
claims. This includes medical and health professionals, facilities, providers, regulatory bodies, insurers, investigators, and administrators of other benefits programs.
I understand and acknowledge that I must submit prior authorization with a written recommendation from the prescribing physician or nurse practitioner,
including diagnosis, and a copy of the provincial plan statement and/or completed a prior authorization form prior to purchasing and submitting claims for homecare,
hearing aids, nursing, orthotics, prosthetic appliances, medical equipment, and medical supplies greater than $300. I also acknowledge that my claim may not
be paid if I don’t submit a prior authorization request to Manulife for items requiring prior authorization. I agree that I acknowledge all exclusions in my contract,
including for benefits not payable for hearing aids, orthotics, prosthetic appliances, medical equipment, and medical supplies greater than Manulife guidelines. I also
agree that I acknowledge that benefits are not payable for items that Manulife deems to be greater than usual, reasonable, and customary, or charges for devices
that don’t appear on Manulife’s list of approved devices. I also agree that I acknowledge that benefits are not payable for charges for duplicate or replacement
hearing aids, orthotics, prosthetic appliances, medical equipment, and medical supplies that are outside Manulife’s guidelines for replacement. I agree that a
photocopy, facsimile, or electronic version of this authorization shall be as valid as the original. If applicable, I authorize Manulife to use the email address provided
as a means of communication with me related to my Individual Insurance health care coverage. I agree that Manulife is not liable for damages which I may have incur
as a result of interception by a third party or an email transmission sent by Manulife or by me pursuant to this authorization. I agree that should the email address
identified on this form change, I am responsible for updating the email address maintained by Manulife. I understand that if I do not wish to receive emails from
Manulife. I can unsubscribe, remove my email address online or contact our contact centre at 1-800-268-3763 to have my email address removed.
CM5000E (08/2020) LH The Manufacturers Life Insurance Company Page 2 of 2
8 Medical
equipment
and
appliances
(continued)
Duration equipment is required: From: Date (dd/mmm/yyyy) To: Date (dd/mmm/yyyy)
Has rental equipment been returned (if applicable)?
Have you received a written recommendation of prescription for this device from a physician or nurse practitioner?
Is the expense for your hearing aid(s), orthotics, prosthetic appliance(s), medical equipment, or medical supplies greater than $300?
If
No
, please explain:
If
No
, please explain:
Yes No
Yes No
Yes No
If
Yes
, before you made your purchase, did you submit a prior authorization request to us that included all of the following? Yes No
We will not pay claims for hearing aids, orthotics, prosthetic appliances, medical equipment, and medical supplies over $300 that did not receive prior authorization.
13 Mailing
instructions
Please mail your completed claim form, original receipts, and prior authorization approval notice for
hearing aids, orthotics, prosthetic appliances, medical equipment, and medical supplies exceeding $300
(if applicable) to:
Manulife Individual Insurance Health Claims
P.O. Box 670, Stn Waterloo, Waterloo, ON N2J 4B8
14 Statement of confidentiality
The specific and detailed information requested on this form is required to process the insured person’s claim request. To protect the confidentiality of this information,
The Manufacturers Life Insurance Company (Manulife) will establish a financial services file. Information in this file will be used to process the application, offer and
administer services, and process claims. Access to this file will be restricted to those Manulife employees, mandataries, and administrators who are responsible for the
assessment of risk (underwriting), marketing and administration of services and the investigation of claims, and to any other person you authorize or as authorized by
law. These people, organizations, and service providers may be in jurisdictions outside Canada, and subject to the laws of those foreign jurisdictions. Your consent to
the use of personal information to offer you products and services is optional and if you wish to discontinue such use, you may write to Manulife at the address shown
below. Your file is secured in our offices or those of our administrator or agent. You may request to review the personal information it contains and make corrections by
writing to: Privacy Officer, Manulife, PO Box 1602, Del. Stn 500-4-A, Waterloo, Ontario N2J 4C6. A copy of our privacy policy is available on manulife.ca.
Accessible formats and communication supports are available upon request. Visit manulife.ca/accessibility for more information.
The Manufacturers Life Insurance Company (Manulife)
Manulife, Manulife & Stylized M Design, and Stylized M Design are trademarks of The Manufacturers Life Insurance Company and are used by it, and by its aliates under license.
© 2020 The Manufacturers Life Insurance Company. All rights reserved. Manulife, PO Box 670, Stn Waterloo, Waterloo, ON N2J 4B8. manulife.ca 1-800-268-3763
Written recommendation/prescription from a physician or nurse practitioner, diagnosis and a copy of the statement from any provincial or territorial funding plan
Email address (Please print clearly)
Complete only
when providing
new or updated
information.
