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CLAIM FORM FOR RELATED HEALTH - providerConnect

CLAIM FORM FOR RELATED HEALTH - providerConnect 2026

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The document is a claim form for related health professional services under Green Shield Canada, detailing various types of health professionals eligible for claims, such as podiatrists, chiropractors, and physiotherapists. It outlines the necessary information required from both the provider and patient, including authorization for treatment and insurance details. The form emphasizes that it is only for services rendered after provincial plan maximums are exhausted and must be submitted within 12 months of service.

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Click ‘Get Form’ to open the CLAIM FORM FOR RELATED HEALTH in the editor.
Begin by filling in the PROVIDER section. Enter the Green Shield Provider Number, Provider Phone Number, and the Name of the Practitioner.
Next, complete the PATIENT section. Input the Patient's Green Shield ID number, surname, first name, birth date, and address details.
Specify the Profession Type Code from the provided list that corresponds to the services rendered.
Indicate treatment details including Date of Last Visit covered by Provincial Plan and Treatment Rendered. Fill in any applicable hours and charges.
Answer questions regarding other insurance coverage and motor vehicle accidents as necessary.
Both provider and patient must sign at designated areas to certify that all information is accurate before submission.

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