Nexxus Blue Cross Form – Fill Out and Use This PDF

OTHER COVERAGE

Do you or any of your dependents have coverage under any other plan?

	No	If applicable, please provide the termination date (dd/mm/yyyy):
q

DEPENDENT INFORMATION

If the claimant is an over age dependent (as deined in your Plan), please complete the following:

qYes If Yes, complete the following: Name of other Insurer:

Member Name:

ID Number:

Policy Number:

Type of policy (3):

Individual

Group

q

q

Effective Date:

Please indicate type

Hospital

Travel

Extended Health

q

q

q

of coverage (3) :

Drugs

Vision

Dental

All

q

q

q

q

1.Age of Child

2.Is he/she unmarried?

3.Is he/she employed full-time?

4.Is he/she attending school, college or university full-time?

5.Is he/she physically or mentally handicapped and dependent on you for support?

q

q

q

q

Yes Yes

Yes

Yes

q

q

q

q

No No

No

No

Was treatment the result of an accident?

Yes

No

If Yes, please complete the following and attach details of the accident:

q

q

-

Was treatment the result of an automobile accident?

Yes

No

q

q

-

Was treatment the result of an injury in the workplace?

Yes

No

If Yes, has Worker’s Compensation been advised?

q

q

q

Yes

q

No

1

2

3

4

5

6

7

8

9

10

CLAIM INFORMATION

Claimant’s Name		Relationship to	Date of Birth			Type of Service	Drug Identiication	Date of Service			Amount Paid
		Member				E.g. Physiotherapy;	Number (DIN)
First Name	Last Name	Self, Spouse, Child	day	month	year	diabetic supplies; eye	(if applicable)	day	month	year
						glasses; etc.

TOTAL CLAIM AMOUNT

MEMBER STATEMENT

I certify that I have not claimed and will not claim these expenses under any other insurance plan (unless indicated above), and that all information contained herein is correct.

I hereby authorize the release of any information or records requested in respect to this claim to the insurer or its agents and certify that the information given is true, correct and complete to the best of my knowledge.

I understand that the personal information provided herein, as well as any other personal information currently held or collected in the future by my Blue Cross plan may be collected, used, or disclosed to administer and manage the terms of my plan or the group plan of which I am an eligible member or dependent, to recommend suitable products and services to me, and to manage my Blue Cross plan’s business. For

the purposes listed above, limited personal information may be collected from and/or released to a third party. This third party may include another Blue Cross organization, a licensed physician, health care professional or institution, life and health insurer, government and regulatory authorities, the member of any plan under which I am a dependent or another third party.

I understand that my personal information will be kept conidential and secure. I understand that I may revoke my consent at any time, however, in some instances doing so may prevent my Blue Cross plan from providing me with the requested coverage or beneits. I understand why my personal information is needed and I am aware of the risks and beneits of consenting or refusing to consent to its disclosure.

I authorize my Blue Cross plan to collect, use and disclose my personal information as described above.

Signature		Date
(If under 18 years of age, the signature of the member is required)

This consent complies with federal and provincial privacy laws. For additional information regarding your Blue Cross plan’s privacy policies, call 1-888-873-9200.

Please see back page for instructions on how to complete this form and our mailing addresses.

1Complete all areas on the front of this claim form.

2Please refer to your Blue Cross card for your Policy and ID numbers.

3Keep a copy of your receipts and documents for your records.

4All claims must be submitted with itemized statements and original paid-in-full receipts, including the following:

•Claimant’s First and Last Name

•Description of item purchased or service rendered

•Date of each purchase or service

•Amount charged for each purchase or service

•Address and telephone number of supplier / provider

5Claims must be received in our ofice before the claiming deadline.

6An Explanation of Beneits statement indicating how this claim was assessed will be sent to the member. If applicable, it will be accompanied by a cheque.

The statement can be used for income tax purposes or to claim through another insurance plan. Please retain the Explanation of Beneits as no other statements will be issued.

Photocopies are not acceptable, unless the following situation applies.

Other Coverage:

1If you are claiming expenses for your spouse and your spouse is covered under another health beneit plan, you must submit the claim to your spouse’s plan irst.

2If both you and your spouse have health beneit coverage, your children must claim under the plan of the parent with the earliest birthday (month and day) in the calendar year. (Example: if your birthday is May 1 and your spouse is June 5, your children will claim under your plan irst).

3If you have submitted your original receipt to your other insurance company, please provide the following:

•A photocopy of all invoices and paid-in-full receipts.

•Original statement from the other insurance company showing their payment / denial of the claim.

® Registered trademark of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross Plans.

FORM-210(B) 05/12