Fill - Free fillable MEDICAL REIMBURSEMENT PLAN EXPENSE STATEMENT (Great-West Life Insurance for Personal, Group & Benefits in Canada) PDF form

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M6734(D)-2/20

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

MEDICAL REIMBURSEMENT

PLAN EXPENSE STATEMENT

Benefit to be paid: Healthcare/Vision Dentalcare Both

Important Information

An expense is eligible for reimbursement under the Medical Reimbursement Plan if:

• it qualifies under the Income Tax Act (Canada) for the purpose of calculating the medical expense credit, and

• it is either not covered or only partially covered by another public or private health insurance plan.

If The Canada Life Assurance Company (Canada Life) determines that a particular expense is not an eligible expense, the plan

member may wish to obtain independent professional tax advice or contact the Canada Revenue Agency for a formal opinion.

Further information may be obtained by visiting the Canada Revenue Agency website at www.cra.gc.ca or contacting the Canada

Revenue Agency by telephone.

Instructions for Claim Submission

Please:

1. Complete this form in full.

2. Keep a photocopy of this form and your receipts.

3. Staple together and submit:

• this original form

• all supporting receipts and invoices, including the other insurer’s Explanation of Benefits, if applicable

Note: This form must be signed by the plan member.

Part 1: Plan Member Information

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 beneﬁts plan. I authorize Canada Life, any healthcare or dentalcare provider, my

plan administrator, other insurance or reinsurance companies, administrators of government beneﬁts or other beneﬁts 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 afﬁliates’ 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 www.canadalife.com.

▪ ▪ ▪

Group Plan Number Plan Member Identification Number

Plan Member Name

Address: Number and Street Town Province Postal Code

Plan Member Signature

Date

Turn over for side 2

Part 2: Dependent Information

Patient Name

Relationship

to Employee

Date of Birth

Year Month Day

Does patient

reside with you?

YES NO

Full-Time

Student?

YES NO

If child over 18 years

If student, how

many hours

per week?

Employed?

YES NO

How many

hours worked

per week?

Part 3: Coordination of Benefits

Are you or any other member of your family entitled to benefits under any other plan? Yes No

Is any member of your family (other than yourself) insured as an employee under this plan? Yes No

Is treatment required as the result of an accident? Yes No

Is a claim being made for Worker’s Compensation Benefits? Yes No

Part 4: Claim Details

Patient Name Number of

Receipts

Type of Expense Nature of Illness Total Charge

Expenses Submitted to Canada Life

Reimbursement in amounts of $10.00 or less will be processed at your next claim submission and included with your next payment.

Please send your Medical Reimbursement Plan Expense Statement to the benefit payment office that processes all of your

health and dental claims. If you are unsure of the correct benefit payment office, please contact your plan administrator.