Fillable Out-of-Province/ Out-of-Canada Health Claim (OTIP RAEO)

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Out-of-Province/ Out-of-Canada Health Claim (OTIP RAEO)

On average this form takes 13 minutes to complete

The Out-of-Province/ Out-of-Canada Health Claim (OTIP RAEO) form is 2 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 45 other fields

Country of origin: CANADA
File type: PDF

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OOC 09/20
Page 1 of 2
Out-of-Province/
Out-of-Canada Health Claim
(For physician’s fees and hospital services only)
OTIP Health Claims
PO Box 280
Waterloo, ON N2J 4A7
1.866.783.6847 | www.otip.com
INSTRUCTIONS: (Please PRINT CLEARLY.)
• All sections to be completed by the plan member unless otherwise indicated.
• One form must be completed for each patient.
• Claims MUST be submitted to your provincial plan and THEN submitted to OTIP Health Claims with a copy of the statement of payment (or decline).
• The group benets insurance carrier (“Insurer”) will co-ordinate claim assessments on your behalf when you have individual travel health insurance coverage.
• Please attach copies of itemized statements from the provider of services to the BACK of this form. These will not be returned.
• Eligible expenses submitted in a foreign currency will be paid in Canadian funds.
• ANY COST INCURRED AS A RESULT OF OBTAINING ANY ADDITIONAL INFORMATION THAT IS REQUIRED BY OTIP OR THE INSURER IS THE
RESPONSIBILITY OF THE PLAN MEMBER.
SECTION 1: MEMbER bASIC PERSONAL INfORMATION
SECTION 2: PATIENT INfORMATION (Complete for all expenses.)
SECTION 3: CLAIM INfORMATION
Plan Member Name (First, Middle Initial and Last)
Date of Birth (mm/dd/yyyy)
Province Postal Code
City/TownAddress (Number, Street and Apt.)
OTIP Identication Number
Home Telephone Number
Complete if patient is a student, 18 or older
Are these expenses eligible for coverage under any type of worker’s compensation?
Yes No
Is the patient covered under any other travel or group insurance plan for the expenses being claimed? Yes No
If “Yes”, please provide the following information:
1. Describe when, how and where the injury/illness occurred.
* “Ind.” refers to travel insurance purchased by the individual/family. “Group” refers to benets provided through plan sponsor.
Patient’s Name
Date of Birth
(mm/dd/yyyy)
(1st Claim Only)
Date of Departure
(mm/dd/yyyy)
Date of Return
(mm/dd/yyyy)
Relationship to
Plan Member
(1st Claim Only)
School and City
Province/Country where treatment was provided
If employed, hours
worked per week
Name and address
of insurance company
Type
of Policy
Plan Contract
Number
Plan Member Number
Name of person(s)
policy issued to
Ind.*
Group*
1
2
3
4
Plan Number
Email Address
Plan Sponsor
Gender
Male Female
Work Telephone Number
Ind.*
Group*
Ind.*
Group*
Ind.*
Group*
EMERGENCY CARE: Treatment for an injury which occurs or an illness which begins while temporarily outside of province/Canada.
Reset
OOC 09/20
Page 2 of 2
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 benets insurance carrier (“Insurer”) that provides my benets coverage to collect,
use, maintain and disclose personal information relevant to this claim (“Information”) for the purposes of benets 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 benets 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 identication and administration. I agree a photocopy or electronic version of this authorization is valid. I acknowledge that
more specic details regarding how and why OTIP and the Insurer collect, use, maintain, and disclose my personal information can be found in OTIP’s Privacy
Policy available at www.otip.com, or the Insurer’s Privacy Policy available at www.manulife.com, or by request.
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 benets health le. Access to your Information will be
limited to:
t
The Insurer and their reinsurers and service providers in the performance of their jobs;
t
Persons to whom you have granted access; and
t
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
QUESTIONS?
OTIP Benets Services
1-866-783-6847
Direct Deposit
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 prole from the top navigation, then Update banking
information. First-time users, you will need to complete registration.
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Out-of-Province Out-of-Canada Health Claim (OTIP RAEO)

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Completed 6 January 2021

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