Form 4197 Pec 55555 E 02 10 PDF Details

Managing health care plans within the public service sector can often seem complex, but the 4197 PEC 55555 E 02 10 form aims to streamline the process of making essential amendments. This document facilitates significant changes for members of the Public Service Health Care Plan (PSHCP), particularly focusing on positive enrolment changes. Whether members need to add dependents, update contact information, or adjust their coordination of benefits, this form serves as a comprehensive tool to ensure their health care coverage accurately reflects their current needs. Available for completion online or via a paper submission, it provides a versatile option for members to manage their enrollment. The form includes sections for personal identification, information about dependents, spouse or common-law partner details, and a consent to release personal information. With instructions clearly outlined and support provided through Sun Life Assurance Company of Canada, users are guided through the process of submitting their changes efficiently. Additionally, the form reinforces the importance of confidentiality in handling personal information, aligning with the Personal Information Protection and Electronic Documents Act (PIPEDA). By offering a structured way to report changes, the form plays a crucial role in the administration of the PSHCP, ensuring members and their families receive the appropriate health care benefits.

QuestionAnswer
Form NameForm 4197 Pec 55555 E 02 10
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesPSHCP PE Change Form 4197 pe 55555 e 02 10 form

Form Preview Example

Public Service Health Care Plan (PSHCP)

Positive Enrolment Change Form

Date amendment requested (dd-mm-yyyy)

 

Contract number

 

 

–

 

–

 

 

 

055555

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructions

 

 

 

 

Certificate number

 

 

 

 

 

•You can complete this form online at www.sunlife.ca/enrolment_pshcp, rather than submitting a paper form.

•If you need to add more dependants or make changes to more than one dependant, use a photocopy of this form.

•Print clearly in ink, and sign and date the form and mail it.

Questions? Visit www.sunlife.ca/enrolment_pshcp or call toll free 1-877-283-1411 or, in the National Capital Region, 613-560-7846, Monday to Friday, 6:30 a.m. to 8:00 p.m. EST.

Complete this section.

Last name

First name

Date of birth (dd-mm-yyyy)

– –

Complete only the sections you want to change.

1 I Your contact information

 

Permanent address (street number and name, and/or P.O. Box)

 

 

Apartment

 

City

 

 

 

 

 

 

 

 

 

 

Province/State

Postal code/Zip code

Country

 

 

 

Telephone number

––

2 I Your coordination of benefits information

Are you covered under another private group health care plan, other than the PSHCP? Yes No If yes, for Drugs only Medical only Drugs and medical Other

If yes, are you covered as

Employee Retiree Dependant

Is the coverage

Single Family

3 I Information about your spouse/common-law partner

Cease coverage

Add a spouse/common-law partner (if you have family coverage)

Change information about a spouse already enrolled

Last name

First name

Gender

Male

Female

Date of birth (dd-mm-yyyy)

– –

Spouse/common-law partner’s coordination of benefits

 

Is your spouse/common-law partner a member of the PSHCP (other than as your dependant)?

 

If yes, provide your spouse/common-law partner’s PSHCP certificate number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is your spouse/common-law partner covered under another private group health care plan?

Yes

No

 

Is the other plan coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, for

 

Drugs only

 

Medical only

Drugs and medical

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

Family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, as a

 

Member

Dependant (Select “member” if both apply.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4 I Information about your dependant children

Cease coverage

Add a dependant child (if you have family coverage)

Change information about a dependant child already enrolled

 

Last name

 

 

 

 

First name

 

 

 

 

 

Gender

 

Date of birth (dd-mm-yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

–

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship

 

Full-time student (if over age 20)

 

Child with a disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Son

Daughter

Foster child

 

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 2

4197-PEC-55555-E-02-10 (G4821-E)

For HO use only:

GV_CHG

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certificate number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4 I Information about your dependant children (continued)

 

 

 

 

 

 

 

 

Dependant’s coordination of benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is your dependant child covered under another private group health care plan?

Yes

No

If yes, as

Member

Dependant

 

 

 

 

 

 

 

 

 

 

 

 

 

(Select “member” if both apply.)

If yes, for

Drugs only

Medical only

Drugs and medical

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If dependant under another private group health care plan:

 

 

 

 

 

 

 

 

Date of birth of parent covered under that plan (dd-mm-yyyy)

– –

First name of parent with other coverage

5 I Consent to release of personal information and signature

Definitions

The Plan Sponsor is the Government of Canada.

The Plan Administrator is Sun Life Assurance Company of Canada.

The Public Service Health Care Plan (PSHCP) Administration Authority is the corporation charged with the administration of the PSHCP.

Personal information, for the purposes of this Consent, means the personal information described in the PSHCP Privacy Statement.

I have read and I understand the PSHCP Privacy Statement provided to me and that Sun Life Assurance Company of Canada has been retained to provide the administrative services for the PSHCP.

•I authorize the Plan Sponsor, the PSHCP Administration Authority and the Plan Administrator, its agents and service providers, to use and disclose personal information about me and my eligible dependants, for the administration of the PSHCP and for the adjudication of claims;

•I authorize the Plan Sponsor, the PSHCP Administration Authority and the Plan Administrator, its agents and service providers, to use and disclose personal information with other persons and organizations who have, or require, relevant personal information about me and my eligible dependants pertaining to our claims;

•I certify that my spouse and my eligible dependants 18 years of age and over consent to their enrolment in the PSHCP and to the disclosure of their personal information for that purpose;

•I certify that my spouse and my eligible dependants 18 years of age and over authorize the use and disclosure of their personal information for the additional purposes identified above;

•I agree to disclose personal information about my eligible dependants under 18 years of age in order to enrol them in

the Plan, and I authorize the use and disclosure of their personal information for the additional purposes identified above;

•I certify that all dependants named on this form meet the PSHCP eligibility requirements and that the information provided above is complete and accurate;

•I agree to notify the Plan Administrator of any changes to the information provided above;

•I certify that all goods and services for which reimbursement is claimed will have been received by me, my spouse or my eligible dependants, including any dependant 18 years of age and over.

A photocopy or electronic version of this signed authorization is as valid as the original.

Member signature

X

Date (dd-mm-yyyy)

– –

Keeping your information confidential

At all times, the information collected through positive enrolment will be protected under the provisions of the PERSONAL INFORMATION PROTECTION

AND ELECTRONIC DOCUMENTS ACT (PIPEDA).

Mailing instructions – keep a copy of this form for your records

Mail your completed and signed form to:

Sun Life Financial

 

PSHCP Positive Enrolment

 

PO Box 2005, Stn Waterloo

 

Waterloo ON N2J 0A4

Page 2 of 2

4197-PEC-55555-E-02-10 (G4821-E)

For HO use only:

GV_CHG

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Form 4197 Pec 55555 E 02 10 completion process clarified (stage 1)

2. When the first part is filled out, go on to type in the relevant details in these: I Your coordination of benefits, Are you covered under another, If yes are you covered as, Is the coverage, If yes for Drugs only Medical, Employee Retiree Dependant, Single Family, I Information about your, Gender Male Female, Date of birth ddmmyyyy, Spousecommonlaw partners, Is your spousecommonlaw partner a, If yes provide your, Yes No, and Is your spousecommonlaw partner.

Guidelines on how to fill in Form 4197 Pec 55555 E 02 10 part 2

3. Within this stage, check out I Information about your, First name, Relationship, Fulltime student if over age, Son Daughter Foster child, Yes No, Gender Male Female, Child with a disability, Yes No, Date of birth ddmmyyyy, Page of PECE GE, and For HO use only GVCHG. Every one of these are required to be taken care of with highest accuracy.

Stage # 3 in submitting Form 4197 Pec 55555 E 02 10

4. This next section requires some additional information. Ensure you complete all the necessary fields - I Information about your, Dependants coordination of benefits, Is your dependant child covered, If yes for Drugs only Medical, If yes as Member Dependant, If dependant under another private, Certificate number, Date of birth of parent covered, First name of parent with other, I Consent to release of personal, Definitions The Plan Sponsor is, I have read and I understand the, and providers to use and disclose - to proceed further in your process!

Form 4197 Pec 55555 E 02 10 conclusion process detailed (part 4)

It's easy to make a mistake when filling out the I Consent to release of personal, for that reason be sure you take another look before you decide to send it in.

5. The pdf must be finalized by dealing with this part. Further you'll see a full set of form fields that need appropriate information for your document usage to be complete: Member signature X, Date ddmmyyyy, Keeping your information, Mailing instructions keep a copy, Mail your completed and signed, Sun Life Financial PSHCP Positive, Page of PECE GE, and For HO use only GVCHG.

Find out how to prepare Form 4197 Pec 55555 E 02 10 part 5

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