Ospca Ontario Claim Form PDF Details

When pet owners in Ontario find themselves facing veterinary bills due to their pet's illness or injury, navigating the financial aspect can be daunting. Enter the OSPCA Ontario Claim Form, a key document for those with insurance policies underwritten by Northbridge General Insurance Corporation. This form serves as a gateway to potentially receiving coverage for veterinary expenses. It's crucial for policyholders to fill out all sections of the form meticulously and provide comprehensive documentation, including a detailed itemized invoice of the paid treatments and the pet's complete medical history from both current and previous veterinary clinics. The Claims Checklist is an invaluable tool that guides policyholders through the process, ensuring no crucial details are overlooked, such as including the policy number, contact information, and ensuring that the treating veterinarian fills out the necessary sections. The form also requires the policyholder's signature in the Declarations Section, an attestation to the truthfulness and accuracy of the provided information. A lack of completeness or accuracy in filling out this form, or failing to attach necessary documents like detailed medical records and paid, itemized invoices for the treatments undergone, can lead to delays or even denial of the claim. Recognizing the specific requirements, such as the exclusion of transaction histories and account summaries in lieu of detailed, itemized, and paid invoices, is essential for a smooth claims process. The form not only facilitates a structured submission but also serves as a declaration of the accuracy and honesty of the information provided by both the pet owner and the veterinarian, underlining the importance of transparency in the claims process. With diligent attention to the form's requirements, pet owners can navigate their way through the claims process with greater ease and confidence.

QuestionAnswer
Form NameOspca Ontario Claim Form
Form Length2 pages
Fillable?Yes
Fillable fields57
Avg. time to fill out11 min 58 sec
Other namesform ospca get, claim ospca pet form, ospca insurance, ospca insurance claim form

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Claim Form

Underwritten by Northbridge General Insurance Corporation

INSTRUCTIONS: Please complete ALL sections on this form and submit with your paid itemized invoice and pet’s medical history. Only one claim form per pet. A complete veterinary medical history (records) from both current and previous veterinary clinics is required to process your pet’s ollow the Claims Checklist to avoid delays in processing.

Claims Checklist

Complete Section 1 About You and Your Pet

Include your Policy Number

Include your Contact Information

Review your Policy Documents and Terms and Conditions to see if coverage is available for the current medical condition you are claiming for

Have the treating veterinarian complete Sections 2 and 3

Sign your claim form in the Declarations Section (Section 3) Attach detailed paid invoices for condition(s) you are claiming for

*Missing information, signatures, or required supporting documents will result in delays in processing your claim

Medical Records Include:

Detailed examination or SOAP notes

Lab/pathology/radiology reports

Medical reports from referral or emergency hospitals

Transaction histories and invoices are not accepted

Invoices Must Be:

Detailed and Itemized indicating the cost and treatment

Paid, unless reimbursement is to be made and agreed to by the veterinarian Account Summaries are not accepted

SECTION 1A: Your Pet’s Information

Policy Number:

Pet Name:

 

 

 

Species: Dog

Cat

Breed:

 

Age:

 

 

SECTION 1B: Your Information

Your Name:

Mailing Address:

Email Address:

Home Number:

Cell Number:

Check here if there has been a change to your address or phone number

SECTION 2: About Your Claim To be completed by the treating licensed Veterinarian

Diagnosis

List each separate diagnosis clearly

1

2

3

Date

of

ns and

Total amount

Has this medical condition been

 

 

symptoms

(as noted by you, the

being claimed:

treated previously?

 

 

 

client or the pet’s medical record)

 

 

 

 

 

 

 

 

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

Veterinarian Notes Please also attach veterinary history, radiology, pathology reports, and consultation notes where applicable

Pet’s Weight:

 

KG LB

Body Condition Score (BSC):

 

 

 

1-5 Scale (1=Emaciated, 5=Obese)

1-9 Scale (1=Emaciated, 9=Obese)

When was this pet registered with your practice?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM DD

YY

 

If this pet was referred to you, please give the name of the referring practice:

SUBMIT A CLAIM

Email claims@ospcainsurance.ca

Fax: 1.866.368.7387

Continue to Page 2

 

 

 

 

SECTION 3: Declarations

Policyholder Declaration

Veterinarian Declaration

I declare that my veterinarian recommended the treatment for which I am claiming. The veterinary clinic has completed Section 2 and the particulars given are correct to the best of my knowledge and belief. I agree that my veterinarian may provide information that the company may require to verify a claim. I understand that any misrepresentation or omission of any material fact can result in denial of the claim.

I declare that diagnosis and particulars given in Section 2 in regards to the treatment of this pet are correct to the best of my knowledge and belief. I agree to provide information that the company may require to verify a

claim. I understand that any misrepresentation or omission of any material fact can result in denial of the claim.

Signature of Policyholder

Signature of Veterinarian

Date:

Print Veterinarian Name:

MM DD YY

Date:

MM DD YY

Please submit completed claims by:

CLINIC STAMP

Mail

Email

710 Dorval Drive, Suite 400

claims@ospcainsurance.ca

Oakville, Ontario L6K 3V7

 

Fax

 

1.866.368.7387

 

Questions:

 

Call OSPCA Claims at

 

1.866.600.2445

 

 

 

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Mention the essential data in Pets, Weight KG, LB, Body, ConditionS, core, BSC MM, DD, YY SUBMIT, A, CLAIM Email, claim, so, spc, a, insurance, ca Fax, and Continue, to, Page section.

part 3 to filling out form ospca form

The PLEASE, MAKE, DIRECT, PAYMENT, TO, select, one Name, of, Account, Holder Account, Number Name, of, Bank Routing, Number SECTION, Declarations Signature, of, Policyholder and Signature, of, Veterinarian field will be applied to provide the rights or obligations of both parties.

stage 4 to entering details in form ospca form

Look at the areas Date, MM, DD, YY Print, Veterinarian, Name Date, MM, DD, YY Email, claim, so, spc, a, insurance, ca Fax, Questions, Call, OS, PCA, Claims, at and CLINIC, STAMP and thereafter fill them out.

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