FORM-106(E) 08/09
TM
The Blue Cross symbol and name are registered trademarks of the Canadian Association of Blue Cross Plans, used under licence by Medavie Blue Cross, an independent licensee of the Canadian Association of Blue Cross Plans.
MEMBER INFORMATION
ID Policy Date of Birth
Number: Number: (DD/MM/YYYY)
Last Name: First Name:
Address:
City: Province: Postal Code:
Home Telephone Number: Work Telephone Number:
Has your mailing address changed since your last claim? Yes No If yes, signature of member is required for validation:
Claimant’s Name
First Name Last Name
Relationship to
Member
Self, Spouse, Child
Date of Birth Amount
Paid
day month year
CLAIM INFORMATION
TOTAL CLAIM AMOUNT
Date of Service
day month year
Type of Service
EX: Podiatry;
diabetic supplies;
eye glasses; etc.
Example: ED SMITH Self 01 05 1980 Drugs 01 10 2007 $35.00
1
2
3
4
5
6
7
8
9
10
MEMBER STATEMENT
I certify that I have not claimed and will not claim these expenses under any other insurance plan (unless indicated above) and that all information contained herein is correct.
I hereby authorize any health care providers to release to Medavie Blue Cross any information that relates to or supports claims submitted on my behalf, and certify that the information given is true,
correct and complete to the best of my knowledge.
I understand that the personal information provided herein, as well as any other personal information currently held or collected in the future by Medavie Blue Cross and/or Blue Cross Life
Insurance Company of Canada, may be collected, used, or disclosed to administer the terms of my policy or the group policy of which I am an eligible member, to recommend suitable products
and services to me, and to manage Blue Cross’s business. Depending on the type of coverage I carry, limited personal information may be collected from and/or released to a third party.
These third parties include other Blue Cross organizations, health care professionals or institutions, life and health insurers, government and regulatory authorities, the subscriber of any policy
under which I am a participant and other third parties when required to administer and manage the benefits outlined in the policy of which I am an eligible member.
I understand that my personal information will be kept confidential and secure. I understand that I may revoke my consent at any time, however, in some instances doing so may prevent Blue
Cross from providing me with the requested coverage or benefits. I understand why my personal information is needed and I am aware of the risks and benefits of consenting or refusing to
consent to its disclosure.
I authorize Medavie Blue Cross to collect, use and disclose my personal information as described above.
Signature Date
(If under 18 years of age the signature of the member is required.)
This consent complies with federal and provincial privacy laws. For additional information regarding privacy policies at Medavie Blue Cross, visit
www.medavie.bluecross.ca or call 1-800-667-4511.
* Please ensure all areas are complete. Incomplete information may delay processing.
* Please attach all original paid-in-full receipts. If receipts were submitted to another plan and the unpaid portion is now being claimed, please attach copies of all receipts, invoices
and applicable referrals along with the original “explanation of benefits” statement from the other insurer.
* Prescription drug receipts must indicate: name, strength and quantity of drug, drug identification number (DIN), prescription number (RX) and patient name.
* All receipts must indicate: name of supplier/provider, item/service rendered, provider telephone number.
MEDAVIE BLUE CROSS ADDRESSES
New Brunswick and
Prince Edward Island
644 Main St PO Box 220
Moncton NB E1C 8L3
Inquiries: 1-800-667-4511
Newfoundland and Labrador
66 Kenmount Road, Suite 102
Kenmount Business Centre
St. John's NL A1B 3V7
Inquiries: 1-800-667-4511
Nova Scotia
230 Brownlow Ave, Dartmouth
PO Box 2200 Halifax NS B3J 3C6
Inquiries: 1-800-667-4511
Ontario
185 The West Mall Suite 1200
Etobicoke ON M9C 5P1
Inquiries: 1-800-355-9133
MEMBER HEALTH CLAIMS
SUBMISSION FORM
OTHER COVERAGE
Do you or any dependents have other coverage under any other plan? Yes No
If Yes, complete the following:
Name of other Insurer:
Member Name: ID No:
Type of policy (
):
Individual
Group Policy No.:
Effective Date: Termination Date:
Please indicate type of Coverage (
): Hospital Extended Health
Dental Vision Drugs Travel HSA
All
Was treatment the result of an accident? Yes No
If yes, please complete the following and attach
details of the accident
1) Was treatment the result of an
automobile accident? Yes No
2) Was treatment the result of an
injury in the workplace? Yes No
If Yes, has Worker’s Compensation
been advised? Yes No
click to sign
signature
click to edit
![]()
