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SECTION 3: CLAIM INfORMATION (CONTINUEd)
SECTION 4: CERTIfICATION ANd AUTHORIzATION
2. Was the patient previously treated for this condition any time prior to leaving the province or Canada? Yes No
If “Yes”, please attach a letter from the treating Canadian physician stating the previous treatment rendered.
3. Did you receive a discount from the provider of service for any of the bills/invoices submitted? Yes No
If “Yes”, please submit original discounted bills/invoices for processing.
Additional comments regarding the Emergency Care Claim:
I certify that I, my spouse and/or my dependants of minor or major age (“Dependants”), have received all goods or services claimed and that the information
provided for this claim is true and complete. I authorize OTIP and the group benets insurance carrier (“Insurer”) that provides my benets coverage to collect,
use, maintain and disclose personal information relevant to this claim (“Information”) for the purposes of benets plan administration, audit and the assessment,
investigation and management of this claim (“Purposes”). I am authorized by my Dependants to disclose and receive their Information, for the Purposes. I
authorize any person or organization with Information, including any medical and health professionals, facilities or providers, professional regulatory bodies,
any employer, plan administrator, plan sponsor, insurer, investigative agency, and any administrators of other benets programs to collect, use, maintain and
exchange this Information with each other and with OTIP, the Insurer and their reinsurers and/or service providers, for the Purposes. I authorize the use of my
OTIP ID number for the purposes of identication and administration. I agree a photocopy or electronic version of this authorization is valid. I acknowledge that
more specic details regarding how and why OTIP and the Insurer collect, use, maintain, and disclose my personal information can be found in OTIP’s Privacy
Signature of Plan Member Date (mm/dd/yyyy)
Any Information provided to or collected by the Insurer in accordance with this authorization, will be kept in a benets health le. Access to your Information will be
The Insurer and their reinsurers and service providers in the performance of their jobs;
Persons to whom you have granted access; and
Persons authorized by law.
You have the right to request access to personal information in your le, and where appropriate, to have any inaccurate information corrected.
SECTION 5: MAILINg INSTRUCTIONS
Please mail your completed claim form and receipts to the address below.
OTIP Health Claims
PO Box 280
Waterloo ON N2J 4A7
OTIP Benets Services
Receive your claim payments faster with direct deposit and enjoy the
convenience of seeing your claim statements online.
Visit www.otip.com and log in. Once you have logged in to ‘My Claims’,
choose My prole from the top navigation, then Update banking
information. First-time users, you will need to complete registration.