docIndustrial Alliance Claim Form for Medical Expenses
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Industrial Alliance Claim Form for Medical Expenses
GROUP INSURANCE According to your province of residence, please submit form to: Quebec Group Health and Dental Claims PO Box 800, Station Maison de la Poste Montreal, Quebec H3B 3K5 CLAIM FORM MEDICAL EXPENSES Claim Estimate Ontario, Atlantic and Western Provinces Group Health and Dental Claims PO Box 4643, Station A Toronto, Ontario M5W 5E3 1. PRIMARY MEMBER INFORMATION Member’s last name _______________________________________ First name____________________________________________________________ Group policy no. __________________ Certificate no. ___________________ Company/Association name _____________________________________ Y M D Date of birth Sex: M F Language: English French Preferred method of contact for the purpose of claims resolution: Telephone ______________________________________ Email address __________________________________________________________ Complete this section only if your information has recently changed. Member’s Address _________________________________________________________________________ Postal Code ______________________ 2. COORDINATION OF BENEFITS (Complete this section only if your spouse or dependent children are covered by another group plan.) s)FYOURSPOUSEORDEPENDENTCHILDRENARECOVEREDUNDERTHEIROWNGROUPPLANFORMEDICALBENEFITSTHECLAIMMUSTFIRSTBESUBMITTEDTOHISHERGROUPINSURANCE CARRIER9OUMAYSUBSEQUENTLYSUBMITACLAIMTO)NDUSTRIAL!LLIANCEFORTHEUNPAIDPORTIONIFAPPLICABLE s)FYOURINSUREDDEPENDENTCHILDRENARECOVEREDUNDERYOURPLANASWELLASUNDERYOURSPOUSESGROUPPLANTHECLAIMMUSTBESUBMITTEDTOTHEPLANOFTHE PARENTWHOSEBIRTHDAYCOMESFIRSTDURINGACALENDARYEAR )SYOURSPOUSEORDEPENDENTCHILDRENCOVEREDBYANOTHERGROUPPLANFORMEDICALBENEFITS (EALTH#OVERAGE No 9ESPLEASECOMPLETETHEINFORMATIONBELOW &AMILYNAMEOFINSUREDSPOUSECHILD _________________________________________ Date of birth )NDIVIDUAL Y M D Are you claiming any expenses for your spouse or dependent children that are NOT COVEREDUNDERTHEIRPLAN No 9ESPLEASESPECIFYTHEBENEFIT ________________________________________________________________________________________________________ )FYOURSPOUSESGROUPINSURANCECARRIERISALSO)NDUSTRIAL!LLIANCEDOYOUWANTUSTOAPPLYCOORDINATIONOFBENEFITS No 9ESPLEASESPECIFY Spouse’s group policy no. ______________________________________________ Certificate no.___________________________________________________________ 3. MEDICAL EXPENSES s4OENSURETHECOMPLETERESOLUTIONOFYOURCLAIMPLEASEPROVIDETHEREQUIRED INFORMATIONASOUTLINEDONTHEREVERSESIDEOFTHISFORM &ORCHILDRENANDOVERORACCORDINGTOYOURPLAN s Attach the original receipts and keep a copy for income tax purposes and the coordination of benefits. The receipts will not be returned Handicapped Full-time and they will be destroyed 60 days after the received date. Name/NELINEPERCLAIMANT Relationship to member child No Yes Date of birth Y M student No Yes Name of school Total Expenses PERCLAIMANT D ____________________ ________________ ___________________________ $ ___________ ____________________ ________________ ___________________________ $ ___________ ____________________ ________________ ___________________________ $ ___________ ____________________ ________________ ___________________________ $ ___________ )FTHECLAIMISTHERESULTOFANACCIDENTPLEASESPECIFYTYPEOFACCIDENTDETAILSONREVERSESIDEIFAPPLICABLE Y M Work -OTORVEHICLE D /THER????????????????????? Date of accident 4. MEMBER CONFIRMATION/AUTHORIZATION I HEREBY CONFIRM: THATTHEINFORMATIONCONTAINEDINTHISCLAIMFORMISTRUEANDCOMPLETETOTHEBESTOFMYKNOWLEDGE THATTHEPERSONSFORWHOM)AMMAKINGACLAIMAREELIGIBLEANDTHATIFTHECLAIMISBEINGMADEONBEHALFOFADEPENDENT)AM!54(/2):%$TODISCLOSE INFORMATIONABOUTHIMHERWITHRESPECTTOTHECLAIM /NBEHALFOFMYSELFANDMYDEPENDENTS 1. I CONSENT TO THE RELEASE OFTHEINFORMATIONCONTAINEDINTHISCLAIMFORMTO)NDUSTRIAL!LLIANCEITSEMPLOYEESAGENTSREINSURERSSERVICEPROVIDERS ANDOTHERORGANIZATIONSWORKINGWITH)NDUSTRIAL!LLIANCEFORTHEPURPOSESOFUNDERWRITINGADMINISTRATIONANDPROCESSINGOFTHECLAIM 2. I AUTHORIZE ANYHEALTHCAREPROVIDERORPROFESSIONALMEDICALORGANIZATIONINSURANCEORREINSURANCECOMPANYWORKERSCOMPENSATIONBOARDTHE POLICYHOLDERMYEMPLOYERASWELLASANYOTHERPERSONPRIVATEORPUBLICORGANIZATIONORINSTITUTIONTODISCLOSETO)NDUSTRIAL!LLIANCEITSEMPLOYEES AGENTSANDSERVICEPROVIDERSANYINFORMATIONREGARDINGTHETREATMENTANDEXPENSESINCURREDWHICHTHEYMAYNEEDINTHEASSESSMENTOFTHECLAIM 3. I UNDERSTAND AND AUTHORIZETHATINTHEEVENTTHEREISREASONABLESUSPICIONOFORANYEVIDENCEOFFRAUDORABUSEREGARDINGTHECLAIM)NDUSTRIAL !LLIANCEWILLHAVETHERIGHTTOUSEANDEXCHANGEANYINFORMATIONRELATEDTOTHECLAIMWITHANYRELEVANTREGULATORYINVESTIGATIVEORGOVERNMENTBODYANY HEALTHCAREPROVIDERORPROFESSIONALMEDICALORGANIZATIONINSURANCECOMPANYORREINSURERTHEPOLICYHOLDERMYEMPLOYERORANYOTHERPARTYASPROVIDEDBY LAWFORTHEPURPOSEOFINVESTIGATINGANYSUCHFRAUDORABUSE I UNDERSTAND THATPERSONALINFORMATIONMAYBESUBJECTTODISCLOSURETOTHOSEAUTHORIZEDUNDERTHEAPPLICABLELAWSWITHINOROUTSIDEOF#ANADA I AGREE THATAPHOTOCOPYOFTHIS#ONFIRMATION!UTHORIZATIONSHALLBEASVALIDASTHEORIGINAL Y M D Member’s signature X____________________________________________________________ Date &! INDUSTRIAL ALLIANCE CLAIMS SUBMISSION GUIDELINES -EDICALBENEFITSCOVEREXPENSESFORTHEFOLLOWINGWHICHMAYVARYACCORDINGTOYOURPLAN s$RUGS s0ARAMEDICALSERVICES s(OSPITALROOMS s-EDICALAPPLIANCES s!MBULANCETRANSPORTATIONFEES s4RAVELINSURANCE s6ISIONCARE For specific information, please consult your benefits booklet. GENERAL INFORMATION )NDUSTRIAL!LLIANCE&ORMS s / THERCLAIMFORMSINCLUDING(3!FORMSQUESTIONNAIRESANDMOREINFORMATIONCANBEFOUNDONOURWEBSITEAT www.inalco.com. Coordination of Benefits s 4 HISESTABLISHESTHEORDERINWHICHTWOORMOREINSURANCECOMPANIESWILLPAYBENElTSFORTHESAMECLAIMMAXIMUM s &ORDETAILEDINSTRUCTIONSANDSCENARIOSREGARDINGCOORDINATIONOFBENElTSPLEASEREFERTOTHEh#OORDINATIONOF"ENElTS 'UIDEAVAILABLEvONOURWEBSITE #LAIMSRELATEDTOAWORKOR MOTORVEHICLEACCIDENT s )FYOURCLAIMISRELATEDTOAWORKACCIDENTSUBMITTHEINITIALCLAIMTOYOURPROVINCIAL7ORKERS Compensation Board if applicable. s )FYOURCLAIMISRELATEDTOAMOTORVEHICLEACCIDENTSUBMITTHEINITIALCLAIMTOYOURMOTORVEHICLEINSURANCEIFAPPLICABLE Expenses incurred outside of Canada s % XPENSESINCURREDOUTSIDEOF#ANADAAREHANDLEDBY#AN!SSISTANCE&ORINQUIRIESORQUESTIONSCONTACT#AN!SSISTANCEAT 1 800 203 9024. 4HETRAVELINSURANCECLAIMFORMSFROM#AN!SSISTANCESPECIlCTOYOURPROVINCEOFRESIDENCECANBE FOUNDONTHE)NDUSTRIAL!LLIANCEWEBSITE CLAIM REQUIREMENTS /RIGINALDETAILEDRECEIPTS SHOULDINCLUDETHEFOLLOWING s #LAIMANTSFULLNAME s $ATECOSTANDTYPEOFTREATMENT s 3UPPLIEROR0ROVIDERSNAMEANDCREDENTIALS 0ARAMEDICAL3ERVICES EGMASSAGETHERAPY PHYSIOTHERAPY CHIROPRACTICETC s /RIGINALDETAILEDRECEIPTINCLUDINGMEDICALREFERRALIFREQUIREDBYYOURGROUPPOLICY &OOT/RTHOTICS s /RIGINALDETAILEDRECEIPT s #ASTINGTECHNIQUE s #REDENTIALSOFQUALIlEDHEALTHPRACTITIONERWHOPERFORMEDTHECASTING #HIROPODIST#HIROPRACTOR/RTHOTIST0EDORTHIST0HYSIOTHERAPISTOR0ODIATRIST /RTHOPEDIC3HOES s /RIGINALDETAILEDRECEIPT s -EDICALREFERRALFROMAMEDICALDOCTORPODIATRISTCHIROPODISTPHYSIOTHERAPISTORCHIROPRACTOR Hospital Beds & Wheelchairs s s s s /RTHOPEDIC!PPLIANCES EGKNEEBACKBRACES s /RIGINALDETAILEDRECEIPTSPECIFYINGTHETYPEOFAPPLIANCE s -EDICALREFERRALWITHDIAGNOSISANDSYMPTOMS s %XPECTEDLENGTHOFTIMEREQUIRED Nursing Care s 4 HENURSINGCAREBENElTREQUIRESPREAPPROVALFROM)NDUSTRIAL!LLIANCE$OWNLOADANDCOMPLETETHE QUESTIONNAIREANDSUBMITITTO)NDUSTRIAL!LLIANCE9OUCANlNDTHEQUESTIONNAIREINOURWEBSITE /RIGINALDETAILEDRECEIPTINCLUDINGBREAKDOWNOFCHARGES -EDICALREFERRALWITHDIAGNOSISANDSYMPTOMS %XPECTEDLENGTHOFTIMEREQUIRED 0URCHASEDATEOFPREVIOUSAPPLIANCEIFAPPLICABLE If you have any questions or concerns, please contact our Customer Service at 1 877 422-6487. www.inalco.com