Health Care Claim Form PDF Details

Navigating the world of health care claims can often feel like unsnarling a ball of twine—intimidating at first glance, yet manageable with a bit of guidance. The Extended Health Care Claim Form serves as a vital touchstone in this journey, providing a structured medium through which individuals can claim reimbursement for various medical expenses. Unlike dental expenses, which require a separate form, this document encompasses a wide range of medical services and expenses. It emphasizes the importance of accuracy and completeness, urging claimants to print clearly and ensure no section is left unanswered to sidestep any delays in processing. Original receipts must be attached for each expense, with the foresight of keeping photocopies for personal records, underscoring the balance between thorough documentation and personal record-keeping. Furthermore, the form facilitates coordination of benefits by providing sections to declare coverage under other plans, be it personal, a spouse’s, or children's, thereby optimizing the benefits available across different coverages. The authorization and signature section at the conclusion of the form not only signifies the claimant's attestation to the validity of the information provided but also highlights consent for Sun Life to collect, use, and disclose necessary information, threading the delicate balance between personal privacy and the necessity of information sharing for claim processing. This claim form, in essence, encapsulates a microcosm of the health insurance landscape, mirroring the complexities and necessitated diligence inherent in claiming medical expense reimbursements.

QuestionAnswer
Form NameHealth Care Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesextended health care claim form sunlife, sunlife extended health claim form, sun life claim form, extended health care claim form sun life

Form Preview Example

Extended Health Care Claim Form

•Use this form for all medical expenses and services. For dental expenses, please use the Dental Claim Form.

•Please print clearly and be sure all sections are complete to avoid delays in processing your claim.

•Attach the original receipt for each expense claimed and keep photocopies for your records.

•Sign on page 2 and mail your claim to the address at the bottom of page 2. Some plans allow claims to be submitted online at

www.sunlife.ca.

1 | Information about you – be sure to fully complete this section

Contract number

Member ID number

Your plan sponsor/employer

Preferred language of correspondence

m English m French

Your last name

First name

 

m Male

Date of birth (yyyy-mm-dd)

Daytime phone number

 

 

 

 

m Female

–

–

–

–

 

 

 

 

 

 

 

 

 

 

Your address (street number and name)

 

Apartment or suite

City

 

 

Province

Postal code

 

 

 

 

 

 

 

 

 

 

 

2 | Complete this section if you or your spouse are covered under another plan

Send your claims to your own plan first. When you receive your claim statement, send a copy plus copies of your receipts to your spouse’s plan to claim any unpaid amount.

Send your spouse’s claims to their plan first, then send a copy of their claim statement and receipts to your plan. Send your children’s claims first to the plan of the parent whose birthday falls earlier in the year.

Is your spouse a member of another benefit plan? m No m Yes If yes, please provide details below.

Spouse’s last name

First name

Date of birth (yyyy-mm-dd)

Type of coverage

–

–

m Single m Family

 

 

 

Are you claiming any expenses that are NOT covered under your spouse’s plan?

m No

m Yes If yes, please specify:

 

 

 

 

 

 

If your spouse’s benefit plan is with Sun Life Financial, do you want us to process the claim through both benefit plans?

 

Contract number

Member ID number

 

 

m No

m Yes

 

 

 

 

 

 

 

 

 

Spouse’s signature

 

 

 

 

Date (yyyy-mm-dd)

X

 

 

 

 

–

–

 

 

 

 

 

Are you also a member of another benefit plan? m No

m Yes

If yes, please provide details below.

 

 

Type of coverage

m Single m Family

Are you claiming any expenses that are NOT covered under your other plan? m No m Yes If yes, please specify:

What is your employment status under your other benefits

plan?

m Full-time m Part-time m Retired

If your other benefit plan is with Sun Life Financial, do you want us to process the claim through both benefit plans?

m No m Yes

Contract number

Member ID number

3 | Information about your claim

List the names of all persons for whom you are claiming expenses. Add up all the receipts and insert the total amount claimed. Ensure each receipt clearly indicates the type of expense being claimed.

 

 

Date of birth

 

 

 

 

Full-time

 

 

 

Person for whom you are making the claim

 

(yyyy-mm-dd)

 

 

Relationship to you

student

Disabled

Amount claimed

 

 

 

 

 

 

 

 

 

 

 

Last name

First name

–

–

 

 

m Yes

m Yes

$

 

 

 

 

m No

m No

 

 

 

 

 

 

 

 

 

 

 

Last name

First name

–

–

 

 

m Yes

m Yes

$

 

 

 

 

m No

m No

 

 

 

 

 

 

 

 

 

 

 

Last name

First name

–

–

 

 

m Yes

m Yes

$

 

 

 

 

m No

m No

 

 

 

 

 

 

 

 

 

 

 

Last name

First name

–

–

 

 

m Yes

m Yes

$

 

 

 

 

m No

m No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total claimed

 

 

 

 

 

 

 

 

 

 

 

$

Are you attaching receipts for out-of-Canada expenses? m No m Yes

 

 

 

 

 

Date (yyyy-mm-dd)

 

Out-of-Canada expenses claimed

If yes, tell us the date of departure from claimant’s home province. Ensure the

 

 

–

–

 

$

 

 

 

currency and amount are clearly marked on each receipt. We’ll assess your claim

 

 

 

 

 

 

 

 

 

and convert the eligible expenses to Canadian dollars.

 

 

 

 

 

 

 

 

 

Are any of the expenses you’re claiming the result of a work injury?

 

 

 

 

 

m No

m Yes

If yes, did you submit your claim to the workers’ compensation plan in your province, if applicable?

 

 

m No

m Yes

Are any of the expenses you’re claiming the result of a motor vehicle accident?

 

 

 

 

 

m No

m Yes

If yes, did you submit your claim to the automobile insurance plan in your province, if applicable?

 

 

m No

m Yes

Page 1 of 2 EHC-E-11-10

For SLF use:

HCF

4 | Authorization and Signature – you must complete this section

I certify that all goods and services being claimed have been received by me and/or my spouse or dependents, if applicable. I certify that the information in this form is true and complete and does not contain a claim for any expense previously paid for by this or any other plan.

If this claim is being made on behalf of my spouse and/or dependents, I am authorized to disclose information about them, for the purposes of underwriting, administration and adjudicating claims. I confirm that my spouse and/or dependents, if any, also authorize Sun Life Assurance Company of Canada (“Sun Life”) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing my group benefits plan.

I authorize Sun Life and its reinsurers to collect, use and disclose information about me, and if applicable, my spouse and/ or dependents needed for underwriting, administration and adjudicating claims under this Plan to any other organization who has relevant information pertaining to this claim including health professionals, institutions, investigative agencies and insurers. I also understand that information pertaining to this claim may be reviewed in the event this Plan is audited.

In the event there is suspicion and/or evidence of fraud and/or Plan abuse concerning this claim, I acknowledge and agree that Sun Life may investigate and that information about me, my spouse and/or dependents pertaining to this claim may be used and disclosed to any relevant organization including regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purpose of investigation and prevention of fraud and/or Plan abuse.

If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable to me under my benefit plan(s), and the collection, use and disclosure of information about this claim to other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor for that purpose.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of this Plan.

Any reference to Sun Life Assurance Company of Canada or the Plan Sponsor includes their respective agents and service providers.

Member’s signature

X

Respecting your privacy

Date (yyyy-mm-dd)

– –

Your privacy is important to us. We may leverage our strengths in our worldwide operations and in our negotiated relationships with third- party providers to help us service some of our customers. In some instances our employees, service providers, agents, reinsurers and any of their service providers, may be located in jurisdictions outside Canada, and your personal information may be subject to the laws of those foreign jurisdictions.

To find out about our Privacy Policy, visit our website at www.sunlife.ca, or to obtain information about our privacy practices, send a written request by email to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5.

Questions? Please visit www.sunlife.ca or call our toll-free number 1-800-361-6212 Monday - Friday, 8 a.m. - 8 p.m. ET

Mailing instructions – keep a copy of your claim form and receipts for your records

Mail your completed

Sun Life Assurance Company

Sun Life Assurance Company

form to the claims

of Canada

of Canada

office nearest you.

PO Box 11658 Stn CV

PO Box 2010 Stn Waterloo

 

Montreal QC H3C 6C1

Waterloo ON N2J 0A6

Page 2 of 2 EHC-E-11-10

For SLF use:

HCF

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Step number 1 for filling in sunlife claim forms

2. Just after finishing this section, go to the subsequent stage and complete all required particulars in all these blank fields - What is your employment status, m Fulltime m Parttime m Retired, If your other benefit plan is with, m No m Yes, Contract number, Member ID number, Information about your claim, List the names of all persons for, Fulltime student Disabled Amount, Relationship to you, Date of birth yyyymmdd, Last name, Last name, Last name, and Last name.

The right way to fill in sunlife claim forms part 2

People frequently make mistakes while filling out Date of birth yyyymmdd in this area. Be sure you revise everything you enter here.

3. Completing Members signature, Respecting your privacy, Date yyyymmdd, Your privacy is important to us We, To find out about our Privacy, Questions Please visit, Mailing instructions keep a copy, Mail your completed form to the, Sun Life Assurance Company of, and Sun Life Assurance Company of is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

sunlife claim forms completion process explained (step 3)

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