Medavie Blue Cross Health Claim Form

Should all correspondence be sent to the above address? *

Yes No

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

No Yes

Type of Coverage

Individual Group

Checkboxes

Hospital Travel Extended Health Drugs Vision Dental All

Is he/she unmarried?

Yes No

Is he/she employed full-time?

Yes No

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

Yes No

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

Yes No

Was treatment the result of an accident? *

Yes No

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

Was treatment the result of an automobile accident?

Yes No

Was treatment the result of an injury in the workplace?

Yes No

If yes, has Worker's Compensation been advised?

Yes No

*

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 confidential 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 benefits. I understand why my personal information is needed and I am aware of the risks and benefits 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.

Medavie Blue Cross Health Claim Form