Pshcp Out of Country Form

Public Service Health Care Plan PSHCP Claim Form Out-of-Country Claims Comprehensive Coverage PROTECTED once completed. Ce formulaire est disponible en fran ais. Please read all instructions and information make sure that all sections are complete and accurate or this claim will be returned to you. Contract number 055555 I Member information Last name First name Date of birth yyyy-mm-dd Language preference Gender English Certificate number Male French Home telephone number Female Permanent address street number and name City Province/Territory Country Postal code I Coordination of benefits Your claim will be adjudicated based on the coordination of benefits information you provided about yourself and your eligible dependants during positive enrolment. Any discrepancies could result in a delay in payment. If your spouse is a member of another group health care plan he/she must submit his/her expenses under that plan first. Apartment or suite Is your spouse a member of the PSHCP or another plan administered by Sun Life Financial Does your spouse authorize us to process this claim under his/her Yes No If yes provide details below. Last name of spouse Spouse s contract number Spouse s certificate number Signature of spouse X I Complete if claiming expenses for your spouse or dependant children Relationship to you Spouse Son Daughter Other I Information about your claim Please complete this section if you are living outside of Canada and have Comprehensive Coverage under the PSHCP. The of this plan is administered by Mondial Assistance on behalf of Sun Life Assurance Company of Canada* Attach original receipts for each expense claimed* Part A Prescription Drug Expenses Patient s first name Date purchased yyyy-mm-dd Prescription drug name Type of currency Amount charged Page 1 of 2 300H-55555-E-10-10 G5003-E For HO use only HCF Please note that only reimbursements made in Canadian dollars can be directly deposited to the bank account provided to Sun Life. continued Part B Other Medical Expenses Date of service yyyy-mm-dd Type of expense Name of hospital or practitioner Total amount claimed Part A Part B I Authorization and signature Definition of spouse A spouse means the person who is legally married to the member or a person with whom the member has lived for a continuous period of at least one year whom the member has publicly represented to be their spouse and continues to live with as if that person were their spouse as designated by the member. By signing below I certify that all goods and/or services being claimed have been received by me my spouse or my eligible dependant children* I certify that to the best of my knowledge the information in this form is true and complete and does not contain a claim for any expense previously paid for by this or any other plan* I also certify that all claimants on this form continue to meet the plan eligibility requirements. I acknowledge and agree that the terms of my Positive Enrolment Consent to release of personal information apply to this claim* I hereby authorize Sun Life its agents and service providers to collect use and disclose information about me my spouse and my dependants to other persons and organizations including health professionals who have or require relevant personal information about me my spouse and my dependants pertaining to this claim for the purposes of administration audit paying claims and patient safety.