Form Gl3585E PDF Details

Form Gl3585E is a form that is used to request an extension of time to file an income tax return. This form can be used by individuals or businesses, and it must be filed before the original due date of the tax return. There are a number of reasons why you may need to file Form Gl3585E, and the Extension of Time To File Department at the IRS will review your request and let you know if it has been approved. Make sure to submit all required information with your request, or it may not be processed.

Form NameForm Gl3585E
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesQC, mmm, Paramedical, yyyy

Form Preview Example

Retiree Benefits

Extended Health Care Claim

To be completed by the plan member unless otherwise indicated. Original receipts must be attached for all expenses. (Please attach to the back of this form.) Please retain copies for your files as original receipts will not be returned.

1 Plan member information

Plan no.

Certificate no.

Plan sponsor









ENCON Group Inc. (Retiree Benefits)











Plan member name (first, middle initial, last)




Birthdate (dd/mmm/yyyy)











Plan member address (number, street and apt.)


City or town



Postal code










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


Are you, your spouse or dependents covered under any other plan for the expenses being claimed?


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 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


If employed,


School and city

hrs worked



per week








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.

Please complete page 2.

The Manufacturers Life Insurance Company

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GL3585E (04/2004)

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)


Date (dd/mmm/yyyy)

Has rental equipment been returned?


6 Vision care expenses

To be completed by supplier.

Please enclose an itemized receipt indicating:

• patient's name,

• cost of contact lenses,

cost of glasses,

dispensing fee,

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?




• cost of eye exam,

• date of eye exam,

• cost of tinting,

• treatment and

• date dispensed.

Signature of supplier

Date signed (dd/mmm/yyyy)




Claims confirmation

Total amount of ALL receipts submitted

















I certify that all goods or services being claimed have been received by me/my dependents.


must be attached for all







I certify that the information in this form is true and complete, to the best of my knowledge, and does





not contain a claim for any expenses previously paid for by any plan.



I authorize any person or organization who has information pertaining to this claim, including any



health care provider, insurance company, any type of workers' compensation board, investigative



agencies and my plan sponsor, to release and exchange such information requested by Manulife



Financial and/or its claims service providers for the purpose of plan administration including



processing and investigating this claim.





I authorize Manulife Financial and its claims service providers to collect, to use and to exchange with



the persons or organizations listed above any information needed for the purpose of plan



administration including processing and investigating this claim.



If this claim is made on behalf of my spouse and/or dependents, I am authorized to disclose



information about them, for the purpose of plan administration including processing and



investigating this claim.





If my social insurance number is used as my certificate number, I authorize its use for the



identification and administration of my group benefits.



I agree that a photocopy or electronic version of this authorization shall be as valid as the original.


Please sign here









Signature of plan member


Date signed (dd/mmm/yyyy)








At Manulife Financial, we know that confidentiality of personal information is important. Any



information you provide to us will be kept in a Group Life and Health Benefits file. Access to your



information will be limited to:





• our employees and service representatives in the performance of their jobs;



• persons to whom you have granted access; and



• persons authorized by law.





You have the right to request access to the personal information in your file and, if necessary, correct



any inaccurate information.







Mailing instructions

Please mail your completed claim form and receipts to the appropriate address.



If you live outside Quebec:

If you live in Quebec:



Manulife Financial Group Benefits

Manulife Financial Group Benefits



Health Claims

Health Claims



P.O. BOX 1653






The Manufacturers Life Insurance Company

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GL3585E (04/2004)