Greenshield orthotic claim form 2026

1. Click ‘Get Form’ to open the greenshield orthotic claim form in the editor.
2. Begin by filling out the 'Patient' section. Enter your name, Green Shield I.D. number, date of birth, and contact information including telephone number and address.
3. In the 'Provider' section, input the provider's details including their number and any relevant information about your healthcare provider.
4. Indicate if you have other group insurance coverage that may include these services. If yes, provide the insurance company name and Green Shield number if applicable.
5. The dispensing physician must complete their section by prescribing the orthotics, providing a diagnosis, and detailing any diagnostic measures taken.
6. Ensure all charges for treatment are listed accurately in the 'Charges' section along with the date of pickup.
7. Finally, both the provider and patient must sign where indicated to certify that all information is accurate before submitting the form.

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