Transcription of PEBA EXTENDED HEALTH CARE PLAN EMPLOYEE …
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PEBA EXTENDED HEALTH CARE PLAN EMPLOYEE …
PEBA EXTENDED HEALTH care PLAN. EMPLOYEE claim FORM. INSTRUCTIONS. 1. Complete page 1 and 2 of this form in full. All claims under this group benefits plan are submitted 2. Sign and date the form. through the plan member. We may exchange personal 3. Please retain copies for your files as original receipts will not be returned. information about claims with the plan member and a 4. Send to the appropriate Benefit Payment Office for your plan. person acting on his or her behalf when necessary to See PART 9. confirm eligibility and to mutually manage the claims. PART 1 - Plan Member Information 1. You must complete this o PS / GE SGEU and CUPE 600-3 or 600-5 (168850). section fully. o Out-of Scope Management (168853). Plan member number (This number can be located on your 3 in 1 Benefits Card). If you are unsure of your plan name, plan Plan Member Name Last name First name number or plan member number, Plan Member Address (Please ensure address is current with your employer).
M635D(PEBA-GE)-12/15 Continued (page 2 of 2) Page 2 of 2 YOU MUST COMPLETE BOTH PAGES Great-West Life Healthcare Expenses Statement PART 9 - Submitting Your Claim
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