Public Service Health Care Plan (PSHCP) Claim Form …
Page 1 of 2300H-55555-E-10-10 (G5003-E) Public Service Health Care Plan (PSHCP) Claim FormOut-of- country Claims ( comprehensive coverage )PROTECTED once completed. Ce formulaire est disponible en fran read all instructions and information; make sure that all sections are complete and accurate or this Claim will be returned to HO use only: HCFContract number055555 1 I Member informationLast nameFirst nameCertificate numberDate of birth (yyyy-mm-dd) Language preference English FrenchGender Male FemaleHome telephone number Permanent address (street number and name)Apartment or suiteCityProvince/TerritoryCountryPostal codeYour 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 your spouse is a member of another group Health care plan, he/she must submit his/her expenses under that plan first.
Page . 1. of 2 300H-55555-E-10-10 (G5003-E) Public Service Health Care Plan (PSHCP) Claim Form. Out-of-Country Claims (Comprehensive Coverage…
Download Public Service Health Care Plan (PSHCP) Claim Form …
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