Date of Service Left Eye Right Eye
Frames $ a) Initial prescription
Lens for right eye $ b) Prescription change
Lens for left eye $ c) Loss or breakage
Other $ d) Other (please explain)
TOTAL $
Give reasons and specific item cost for “Other” in area 1 (e.g. hardening, tinting, varigray, oversize lenses, etc.)
If glasses tinted, what was tint?
Name of Prescribing Optometrist or Ophthalmologist - if signed by Optician
Signed Date
Telephone Number Address
If yes, name of family member insured Relationship to employee
Name of other insurance company Policy Number
If yes, name of family member
If yes, to either question above, and the patient is a dependent child, please provide spouse’s date of birth: /
/
Year Month Day
If yes, how many hours per week?
PATIENT NAME RELATIONSHIP TO EMPLOYEE DATE OF BIRTH
(Year / Month / Day)
If yes, how many hours per week at school?
M1214D(WPG) BIL-8/14
Employee’s Signature Date
PLAN NUMBER DIVISION NUMBER PLAN NAME
EMPLOYEE IDENTIFICATION NUMBER EMPLOYEE NAME DATE OF BIRTH
(Year / Month / Day)
ADDRESS: NUMBER AND STREET TOWN PROVINCE POSTAL CODE PHONE #
HOME: WORK:
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
VISIONCARE CLAIM FORM
INSTRUCTIONS: Complete a separate form for each family member for whom you are claiming
expenses.
Attach bills for each expense and fully itemize them in the space provided below.
IMPORTANT: If any of the requested information is missing or incorrect, your claim will be
returned.
All claims under this group benefits plan are submitted through the plan member.
We may exchange personal information about claims with the plan member and
a person acting on his or her behalf when necessary to confirm eligibility and to
mutually manage the claims.
SEND THIS CLAIM TO:
Questions? Call Toll Free: 1.800.957.9777
Winnipeg Benefit Payments
PO Box 3050 Station Main
Winnipeg MB R3C 0E6
For the deaf or hard of hearing:
Toll Free: 1.800.990.6654
Please print
PART 1 EMPLOYEE INFORMATION
PART 2 PATIENT INFORMATION
If Dependent, does the patient reside with you? Yes No
If child 18 years or older: a) Full-time student? Yes No
b) Employed? Yes No
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
PART 4 TO BE COMPLETED BY PROVIDER OF MATERIALS
CHARGES FOR
MATERIALS
SUPPLIED
Type of lenses supplied
Plain glass
Single vision
Bifocal
Trifocal
Contact
Reason for purchase (please check)
I am a legally qualified Ophthalmologist Optometrist Optician
At Great-West 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 benefi ts plan. 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 Great-West Life’s Chief Compliance Officer or refer to www.greatwestlife.com.
I authorize Great-West Life, any healthcare provider, my plan administrator, other insurance or reinsurance companies, administrators of government
benefi ts or other benefi ts programs, other organizations, or service providers working with Great-West 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 certify that the information given is true, correct, and complete to the best of my knowledge.
© The Great-West Life Assurance Company. All rights reserved. Any modification of this
document without the express written consent of Great-West Life is strictly prohibited.
