Claim for Healthcare Benefits – 19132A (PDF, 1.7 MB) Opens in a new window.
This form is used to submit claims for prescription drugs and other health related care and services:
- drug expenses
- vision care expenses
- medical care expenses
- paramedical services (chiropractor, massage therapist, physiotherapist, etc.)
- therapeutic equipment and devices
Claims must be submitted
within 12 months of incurring the expense. To make sure your claim is completed adequately, please refer to the following guidelines (PDF, 275 KB) Opens in a new window..
Request for Reimbursement of a medication not included in the Dynamic Therapeutic Formulary (DTF) or of a Brand Name Medication – 13175E (PDF, 1 MB) Opens in a new window.
This form is used to request authorization for the reimbursement of drugs not included on the DTF and/or brand name drugs when their generic equivalents cannot be taken due to medical reasons.
One section of this form must be completed by the attending physician. The insured is responsible for any fees charged for filling out the form.
Claim for Convalescent Care – 98130E (PDF, 1 MB) Opens in a new window.
This form is used to submit a claim for homecare services if this coverage is offered under your policy.
One section of the form is filled out by the physician who recommended the convalescence period and another by health professionals consulted during the convalescence. The insured is responsible for any fees charged for filling out the form.