Transcription of Supplementary Medical and Prescription Drug …
{{id}} {{{paragraph}}}
Example: marketing
Supplementary Medical and Prescription Drug …
Page 1 of 2 EHC-25108-25134-E-03-14 (G2439-E)Page oef2 EeaHC-5e 1 PeSupplementary Medical and Prescription drug claim form 1 | Information about you be sure to fully complete this section Use this form for all Medical expenses and services. For dental expenses, please use the Dental claim form . Please print clearly and be sure all sections are complete to avoid delays in processing your claim . Attach the original receipt for each expense claimed and keep photocopies for your records. Sign on page 2 and mail your claim to the address at the bottom of page number 25108 Prescription claim 25134 Supplementary MedicalEmployee ID number (first eight digits only) I I I I I I IPreferred language of correspondence English FrenchYour last nameFirst name Male FemaleDate of birth (yyyy-mm-dd) Daytime phone number Your address (street number and name)Apartment or suiteCityProvincePostal code 2 | Complete this section if you or your spouse/partner are covered under another plan Send your claims to your own plan first.
Page . 1. of 2 EHC-25108-25134-E-03-14 (G2439-E) Page oef2EeaHC-5e 1Pe. Supplementary Medical and . Prescription Drug Claim Form. 1 | …
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: