Green shield custom 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Provider Number and Provider Name in the designated fields. Ensure that you include a valid telephone number for easy communication.
3. Fill in the Patient's details, including their Green Shield I.D. Number, Date of Birth, and complete address. This information is crucial for processing your claim.
4. Indicate whether there is any other Group Insurance coverage by selecting 'Yes' or 'No'. If applicable, provide the name of the Insurance Company.
5. The prescribing physician must complete their section by detailing the prescribed items (Custom Foot Orthotics or Orthopedic Shoes) and providing a specific diagnosis.
6. Ensure all required documentation is attached, such as diagnostic measures test results and lab invoices, before signing off on the form.
7. Finally, both the provider and patient must sign where indicated to authorize payment and confirm accuracy of information provided.

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