Desjardins Form 02250E – Fill Out and Use This PDF

Desjardins Form 02250E PDF Details

Desjardins Form 02250E is an authorized reimbursement request for members enrolled in a group insurance plan who need to submit health care benefit claims. The document covers supplementary health care, dental care, vision care, out-of-province travel, and accident-related expenses. Completing it accurately and attaching required receipts helps ensure your total claim is processed within the expected timeframe.

Direct Payment to Your Account

Members who prefer to receive reimbursement directly into their bank account can complete the direct deposit authorization section. You will need your financial institution number, branch transit number, and account number. Once set up, payments from your group plan are deposited automatically. Receiving funds this way is faster than waiting for a mailed cheque and eliminates the risk of documents getting lost in transit.

Coordination of Benefits

When you are covered under more than one group insurance plan, the coordination of benefits section lets you claim the total amount of your eligible expenses across both plans. Expenses not covered by the primary plan may be partially or fully reimbursable through the secondary plan. Include an explanation of benefits statement from your primary insurer when submitting a secondary claim.

Out-of-Province and Accident Claims

Members who incur medical costs while traveling outside their home province, or who have accident-related expenses such as a work injury or motor vehicle accident, must complete the relevant sections and provide dates, destination, and reason for travel. A medical certificate from the treating physician may be required for specific out-of-province claims. Retain all original receipts and documentation to support your request.

Dependent and Health Spending Account Claims

The document includes sections for claims related to dependent children, with fields for date of birth, student status, and any functional impairment. An authorized representative may complete and sign on behalf of the member when needed. Members with a Health Spending Account can also use this to submit expenses not covered under the standard group plan, including specific dental or tax-eligible medical costs.

For questions about eligible expense categories, required documentation, or plan-specific rules, contact your plan administrator before submitting. Processing times vary by submission method, with online and mobile submissions through the member portal typically completing within two business days.