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Click ‘Get Form’ to open it in the editor.
Begin by entering your Member Information. Fill in your Contract Number, Last Name, Given Name, and Date of Birth. Ensure that you select your preferred language and provide your contact details including Daytime and Evening Telephone Numbers.
If applicable, complete the section for Spouse or Common-Law Partner. Provide their Full Name, Date of Birth, and indicate if they are covered under another medical plan.
Next, fill out the Children Covered by this Claim section. List each child's name, relationship to you, and their Date of Birth. Indicate if they are disabled or a full-time student.
In the Details of Claim section, attach original receipts for all expenses. Specify if any expenses resulted from an accident and provide details as required.
Finally, complete the Member Certification & Authorization section by signing and dating the form to certify that all information is accurate.

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