Desjardins Form 02250E – Fill Out and Use This PDF

Group Insurance – Health Claims

CLAIM FOR HEALTH CARE BENEFITS

Do you want your claim processed within 2 business days?	üOnline and mobile services	üDirect deposit
Visit desjardinslifeinsurance.com/planmember to find out more.

AIDENTIFICATION – MANDATORY SECTION – This information can be found on your insurance certificate or payment card.

	Policy or group or contract No.		Certificate No.	Name of group or policyholder or employer
	Member's last name and first name			Sex	Date of birth

YYYY MM DD

M F

Address – No., street, apartment

City

Province

Postal code

BDIRECT DEPOSIT SERVICE – Attach a void cheque or provide your bank information below to sign up for direct deposit.

Transit/branch No.	Institution No.	Account No.	001
			$
			⑈033⑈ ⑆04334⑉001⑆ 111⑉112⑉1⑈
Your email address (mandatory)
			⑈033⑈ ⑆04334⑉001⑆ 111⑉112⑉1⑈
			BRANCH NO. INSTITUTION NO. ACCOUNT NO.

Once registered, your reimbursements for health care services will be deposited into this bank account. A notification email will be sent once your claims have been processed, and the explanation of benefits will be posted online rather than mailed. You must be registered on the secure site to consult your explanation of benefits. To register, go to desjardinslifeinsurance.com/planmember.

Desjardins Financial Security Life Assurance Company (DFS), hereinafter Desjardins Insurance, is not responsible for the accuracy of the banking information you

enter and for verifying that the due amounts are deposited into your account.

CCOORDINATION OF BENEFITS

If you are covered by more than one insurance plan, the coordination of benefits may entitle you to a reimbursement of up to 100% of your eligible expenses.

HOW TO SUBMIT A CLAIM WHEN THERE ARE TWO INSURANCE PLANS:

1.The person who has the other insurance plan must submit a claim to their own insurer first and then provide Desjardins Insurance with detailed information about the benefits paid (information found on the explanation of benefits), as well as copies of any receipts.

2.Claims for dependent children must first be submitted under the plan of the parent whose birthday (month and day) comes first in the calendar year.

Name of insurer							Period of coverage
Other	Desjardins						YYYY	MM DD	YYYY	MM DD
				Certificate No.:
	Insurance – Contract No.:						From		To
Type of benefits:			Drugs	Dental care	Supplementary health care			Vision care	Travel
Type of coverage:			Individual	Couple	Single-parent		Family
Last name and first name of the			1.			3.
dependents covered under this
other insurance plan			2.			4.

DHEALTH SPENDING ACCOUNT – If you have this benefit, check the option you would like.

I confirm that I am eligible for a reimbursement of the indicated expenses under my Health Spending Account.

I recognize that I am responsible for paying any taxes that may result from the reimbursement of these expenses and that, for tax or administrative purposes, my plan administrator may have access to a statement of expenses for which I claimed a reimbursement under my Health Spending Account.

If you don't choose an option, the portion of expenses that isn’t covered by your plan will be automatically submitted to the Health Spending Account for reimbursement.

I do not wish to use my Health Spending Account.

Ineligible expenses – I wish to use my Health Spending Account to cover the expenses that are not reimbursed under my group insurance plan.

Spouse's family coverage – I wish to use my Health Spending Account for myself and my dependent children to cover the expenses that are not reimbursed under my group insurance plan. I will not submit a claim to my spouse's insurer (coordination of benefits).

4If your claim is for a dependent, accident-related expenses, out-of-province expenses or an assignment of benefits, please complete the appropriate section on the back of the form.

4Please sign section I and send the form and original receipt to: Desjardins Insurance, C. P. 3950, Lévis (Québec) G6V 8C6

EINFORMATION ABOUT DEPENDENTS – For the period in which expenses were incurred.

I confirm that the persons designated below meet the definition of spouse and

CHILDREN AGED 18 AND OVER OR 21 AND OVER (depending on the contract)

If your child has a functional impairment, please provide us with

dependent child as specified in the contract under which this claim has been submitted.

a medical certificate confirming your child's disability.

1

Last name and first name

Relation

Sex

Date of birth

YYYY

MM

DD

Spouse

Child

M

F

Has a functional impairment

Full-time student – Name of educational institution attended:

YYYY

MM

DD

YYYY

MM

DD

Period:

From:

To:

2

Last name and first name

Relation

Sex

Date of birth

YYYY

MM

DD

Spouse

Child

M

F

Has a functional impairment

Full-time student – Name of educational institution attended:

YYYY

MM

DD

YYYY

MM

DD

Period:

From:

To:

3

Last name and first name

Relation

Sex

Date of birth

YYYY

MM

DD

Spouse

Child

M

F

Has a functional impairment

Full-time student – Name of educational institution attended:

YYYY

MM

DD

YYYY

MM

DD

Period:

From:

To:

In the case of a change of spouse, please indicate:

IMPORTANT – Please note that the claim must first be submitted under your provincial workers’ compensation plan or automobile insurance plan (if applicable in your province) before being submitted to your group insurance plan.

GOUT-OF-PROVINCE EXPENSES

This is not a travel insurance form. Visit desjardinslifeinsurance.com/travel-claim to find the correct form.

Please include the original receipt itemizing all of your out-of-province expenses.

YYYY

MM DD

YYYY

MM DD

Address – No., street, suite

City

Province

Postal code

I understand that the expenses being claimed may not be covered by the insurer or may exceed the maximum benefit payable. I also understand that I am responsible for paying these expenses. I hereby assign benefits payable to the health care provider designated above and authorize the insurer to pay this provider

directly.

Signature of the member:		Date:
Health care provider's signature:		Date:

IDECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION

All the information I have provided on the claim form is accurate and complete. I acknowledge having read the Personal Information Management section. I authorize Desjardins Insurance, strictly for the purposes of managing my file and settling this claim to: a) collect from any person or legal entity, or from any public or parapublic organization, only the information deemed necessary to manage my file. The non-exhaustive list of sources from which information may be collected includes health care professionals or facilities, insurance companies; b) communicate to the said persons or organizations only the personal information about me that is deemed necessary for the purposes of my file; c) when necessary use the personal information it may have about me in existing files that are now closed. This authorization is also valid for the collection, use and communication of personal information concerning my dependents, insofar as applicable to the claim. A photocopy of this authorization is as valid as the original.

Signature of the member:		Date:
Telephone Nos: Home:	Office:	Extension:

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PERSONAL INFORMATION MANAGEMENT

Desjardins Insurance handles the personal information it has on you in a confidential manner. Desjardins Insurance keeps this information on file so that you may benefit from group insurance services offered by the Company. This information is consulted solely by Desjardins Insurance employees who need to do so in the course of their work. Desjardins Insurance may compile anonymized personal information for statistical and informational purposes. Desjardins Insurance may also communicate with plan members to provide them with optimal health management. You have the right to consult your file. You may also have information corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a written request to the following address: Privacy Officer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance may use the client list to offer its clients an insurance product following the termination of their group insurance. If you do not wish to receive these offers, you may have your name removed from the list. To do so, you must send a written request to the Privacy Officer at Desjardins Insurance.

Please send to: Desjardins Insurance, C. P. 3950, Lévis (Québec) G6V 8C6

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