R:\Communications & Process Changes\Coughlin - Generic\External\Forms\Claims forms\Coughlin Medical Claim Form - Winnipeg.docx Page 1 of 1
Issued: July 2018
MEDICAL EXPENSE CLAIM FORM
Complete this form for all medical expenses and services. For
dental expenses, complete the Dental Expense Claim Form.
Print clearly and ensure that all required sections are completed.
An incomplete form may result in a delay in processing.
Attach the original receipt for each expense claimed and retain a
copy for your records.
4. Sign and date the form and return to Coughlin & Associates Ltd. for processing.
PO Box 764
Winnipeg, MB R3C 2L4
E-mail:
winnclaims@coughlin.ca
1-888-204-1234
Fax: 204-942-2741
www.coughlin.ca
1. PLAN MEMBER INFORMATION
Date of birth (yyyy/mm/dd)
correspondence
☐
☐
2. COORDINATION OF BENEFITS How to submit a claim when there are two plans
Send your claims to your own plan first. When you receive your explanation of benefits, send it along with copies of your receipts to your spouse’s plan to
claim any unpaid amount.
Send your spouse’s claims to their plan first, then send a copy of their explanation of benefits and receipts to your plan.
Send your children’s claims first to the plan of the parent whose birthday (month and day) occurs first in the calendar year.
Are any of the expenses associated with a work related incident AND eligible for workers’ compensation benefits? ☐Yes ☐No
If yes, submit these expenses to your provincial workers’ compensation board.
Are any health benefits or services provided under any other group insurance or health plan or government plan? ☐Yes ☐No
If yes, who is the member of this other plan? Name _________________ Date of birth (yyyy/mm/dd)____________ Relationship to plan member __________
If your other benefit plan is with Coughlin, do you want us to process the claim through both benefit plans?
☐
☐
No If yes, complete the following:
3. CLAIM INFORMATION For equipment and appliance expenses, a written recommendation from the prescribing physician is required, including
diagnosis and a copy of the provincial plan statement of payment (if applicable).
Patient last name Patient first name
Type of expense
Date of birth
(yyyy/mm/dd)
Relationship to
plan member
Full-
student
Disabled
child
Amount claimed
☐
☐
☐
☐
☐No
☐
☐No
$
☐
☐
☐Vision
☐No
☐No
$
☐
☐
☐
☐
☐No
☐
☐No
$
☐
☐
☐Vision
☐No
☐No
$
4. VISION CARE EXPENSES Complete only if submitting a vision care expense
Is this a new prescription? ☐Yes ☐No
Check one (if applicable)
☐ Occupational safety glasses
☐ Prescription sunglasses
☐ As a result of cataract surgery (attach physician’s
recommendation)
5. HEALTH CARE SPENDING ACCOUNT Complete only if you have this benefit
I confirm that I am eligible for a reimbursement of the indicated expenses under my Health Care Spending Account (HCSA). I understand that I must first submit
my claim using the co-ordination of benefits with my spouse’s plan, if applicable.
☐
I do not wish to use my HCSA
☐
I wish to use my HCSA to cover the expenses that are not reimbursed under my group insurance plan
Attach your original receipts to this form and keep photocopies for your files. The original copies will not be returned. Your explanation of benefits and the copies
of your receipts are sufficient for coordination of benefit purposes. Claims MUST BE submitted no later than the period defined in your benefit booklet.
7. AUTHORIZATION & DECLARATION
I authorize Coughlin & Associates Ltd. (“Coughlin”) to collect, use, maintain and disclose my personal information with the following persons, organizations or parties: health
care providers; companies affiliated with Coughlin; financial institutions; government agencies; insurance companies and their reinsurers and/or service providers;
employers or former employers; my local union; plan trustees and auditors for the purposes of plan administration, audit, assessment, investigation, claim management,
underwriting and for determining plan eligibility (as applicable). When providing personal information for my spouse and/or dependants, I confirm that I am authorized to act
on their behalf. I agree that a photocopy or electronic copy of this form is as valid as the original. I certify that the information given is true, correct and complete to the best
of my knowledge.
Protecting your personal information: Coughlin recognizes and respects every individual’s right to privacy. We are committed to keeping personal information private,
confidential, accurate and secure. When personal information is provided to us, we establish a confidential file that is kept in our office, or the office of an organization
authorized by us. Personal information is kept in a secure environment. We limit access to personal information in your file to Coughlin staff or persons authorized by
Coughlin who require access to perform their duties, to persons to whom you have granted access, and to persons authorized by law. We use the personal information to
administer the plan. You may exercise certain rights of access to the personal information in your file, and where appropriate, to have inaccurate information corrected by
sending a written request to Coughlin. For information on our Privacy Policy, visit our website at www.coughlin.ca, or send a written request to our Privacy Officer by mail or
by email at privacy@coughlin.ca.
You must print THEN sign this form
You must print THEN sign this form
