Form Gl3585E – Fill Out and Use This PDF

Are these expenses eligible for coverage under any type of workers' compensation board?

YesNo

YesNo

If "Yes," please retain photocopies of all receipts submitted with this claim for submission to your secondary carrier. If this is your first claim, or if information has changed, please provide the following:

Spouse’s date of birth (dd/mmm/yyyy)

Name of spouse’s insurance company

Spouse’s plan no.

Spouse’s certificate no.

Banking information for direct deposit

Electronic claim statements

To have this and all future claims payments deposited directly into your bank account, attach a void cheque to this claim form and indicate "Yes," in the box below.

Yes, I have attached a void cheque and would like all my future claims payments deposited into this account.

If you have separate plan numbers for Health and/or Dental coverage under your Manulife Group Benefits Plan, please include these plan numbers (listed on your wallet identification card) in the box below.

Did you know you can receive an e-mail alerting you when your claim has been processed? Go to www.manulife.ca/groupbenefits and choose, "Plan Member". You must be registered to use the Secure Site. Log-in and select, "Electronic Claim Statements" from the side navigation bar.

2Patient information

Complete for all expenses. Use one line per patient.

Patient’s name

Date of birth (dd/mmm/yyyy) (1st Claim only)

Relationship to

plan member (1st Claim only)

Complete if patient is a student 18 or older

3Prescription drug expenses

•Attach your prescription drug receipts to the back of this form.

•All receipts must contain the drug identification number (D.I.N.) and the name of the prescription drug.

•You are not required to list this information on the form.

4Practitioner’s/ Paramedical expenses

(e.g. chiropractor, massage therapist, physiotherapist, etc.)

For practitioner/paramedical expenses please attach an itemized statement and/or receipt stating:

•patient name,

•name of practitioner,

•type of practitioner,

•date of service,

•length of visit,

•charge for treatment,

•date last paid by provincial plan (if applicable) and

•licence and/or registration number.

If for psychotherapy, please indicate type (individual, family, group, marriage) on your receipt.

5Equipment and appliance expenses

For equipment and appliance expenses Manulife Financial requires a written recommendation from the prescribing physician, including diagnosis, and a copy of the provincial plan statement of payment (if applicable).

Indicate the activities requiring the use of this item.

Duration equipment is required. From

Date (dd/mmm/yyyy)

To

Date (dd/mmm/yyyy)

Has rental equipment been returned?

YesNo

6 Vision care expenses

To be completed by supplier.

Please enclose an itemized receipt indicating:

Medically necessary contact lenses:

Please have the supplier complete and sign below.

Were contact lenses prescribed for severe corneal astigmatism, keratoconus or aphakia?

Can visual acuity be improved by at least 2 lines on the Snellen chart over the best possible vision with glasses?

Could visual acuity be improved up to at least the 20/40 level by glasses?

YesNo

YesNo

YesNo