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BENEFICIARY DESIGNATION - HealthSource Plus
BENEFICIARY DESIGNATION Please print clearly, use INK, sign and date the form. 1 EMPLOYEE INFORMATION. To be completed by Employee INSTRUCTIONS GUIDE
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Fax Requests to 905-949-3029 - HealthSource Plus
www.healthsourceplus.comSP-A1 (2002/01) SPECIAL AUTHORIZATION REQUEST Fax Requests to 905-949-3029 OR Mail Requests to Clinical Services, ClaimSecure Inc., Suite 620, 1 City Centre Drive, Mississauga, Ontario, L5B 1M2
Standard of procedures special authorization …
www.healthsourceplus.com1 UPDATED March 3rd, 2014 Standard of procedures Special Authorization Drugs 1) General Section For all of the following drugs: Claims should be coordinate with the Provincial government program when available.
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