GENERAL CLAIM SUBMISSION FORM (For Drug …

1 *NO STAPLES PLEASE, PAPER CLIPS ONLYGENERAL CLAIM SUBMISSION form (For drug and Extended Health Claims)SECTION 1 - PLAN MEMBER INFORMATIONEMAIL ADDRESSGREEN SHIELD canada ID NUMBERPHONE NUMBERSURNAMEFIRST NAMECOMPANY NAMECITY OF TORONTOADDRESSPOSTAL CODECITY PROVINCESECTION 2 - MANDATORY DECLARATIONDo you have any other group insurance coverage that may include these services as benefits? YESNOIf Yes, please provide Insurance company's name _____If other coverage is with Green Shield canada , indicate other Green Shield canada ID number: _____Do you want to coordinate this CLAIM with your other Green Shield canada Coverage?YESNODo you want to coordinate this CLAIM with your Health Care Spending Account (if applicable)?YESNOIs treatment due to a motor vehicle accident?YESNOIf yes, Date of Accident (YY/MM/DD) _____Is treatment required due to a work related injury? YESNOIf yes, Date of Injury (YY/MM/DD) _____WSIB / WCB Case # _____SECTION 3 - CLAIM DETAILSTOTALAMOUNTCHARGED PER VISIT/ITEMTYPE OFEXPENSEDATE OF CLAIMYRMODAYPROFESSIONAL/SUPPLIER'S NAMEand Provider Number (if available)DATE OF BIRTHYRMODAYDEPENDENTNO.

2 (-00, -01,-02)PATIENT'S NAME(Only include names of patientswith receipts attached)FOR PARAMEDICAL PRACTITIONER EXPENSES:NOT APPLICABLE TO NON-UNION / ACCOUNTABILITY OFFICERS / ELECTED OFFICIALS, FIREFIGHTERES' AND CUPE LOCAL 79 RECREATIONWORKERSFor the following practitioners ( Chiropractor, Podiatrist, Massage Therapist) choose only ONE of the coverage options:Option 1: the current maximum per practitioner per person, per benefit yearOR, alternativelyOption 2: a maximum of $800 for one (1) practitioner per person, per benefit yearIf option 2 is selected, please indicate the practitioner type here _____, benefit year _____, andPatient s Name practitioner / paramedical expenses please attach an itemized statement and/or receipt stating: Date of service, and Charge for treatment, Length of visit, Patient Name, License and/or registration number Date last paid by provinceplan (if applicable) Type of practitioner, Names of practitioner,SECTION 4 - AUTHORIZATIONI am authorized by my spouse and/or dependents to disclose and receive information about them that is used for the purpose of claims adjudication and any other services necessary inthe administration of our benefits.

3 I understand that this information may be seen by the cardholder. I understand that the information provided by me to Green Shield canada about myselfand my dependents, will be used by Green Shield canada for these the event of suspected fraudulent activity pertaining to claims submitted on behalf of myself and/or my dependents, I acknowledge and agree to the disclosure of this information torelevant parties, such as the Plan Sponsor, regulatory and law enforcement certify that the information in this form and any further verbal or written statement provided by me in the future, is true and complete, to the best of my knowledge. I agree that both myclaim and my coverage may be denied or terminated as a result of my providing false, incomplete or misleading authorize any health care provider, other insurance company, any type of workers' compensation board, my plan sponsor, or other persons to release, discuss and exchange informationrequested by Green Shield canada , when the information is needed to process, litigate, arbitrate or audit this authorize any person or organization who has personal information about me, including my employer, my plan sponsor, any group plan administrator, health care professional, health careinstitution, pharmacy and other medically-related facility, rehabilitation provider, insurer, administrators of government benefits or their benefits programs, the medical information bureauand investigative agency.

4 To release my personal information to Green Shield canada and/or its service providers for the purposes of group benefits plan administration, audit, and theassessment, investigation and management of my CLAIM , including independent medical assessments. Such persons shall be considered persons to whom I have granted access for thepurpose of this "agreement, authorization and consent."I authorize Green Shield canada , its reinsurers and its service providers to collect, to use, to maintain and disclose to the persons to whom I have granted access and/or each other anyinformation needed for the purposes of group benefits plan administration, audit, and the assessment, investigation and management of my CLAIM , including independent medical my social insurance number is used as my certificate number, I authorize its use for the identification and administration of my group agree that photocopy, fax, or electronic versions of this authorization shall be as valid as the Green Shield canada , we know that confidentiality of personal information is important.

5 Any information you provide to us will be kept in a Group Life and Health Benefits file. Access toyour information will be limited to: our employees and representatives in the performance of their jobs; persons to whom you have granted access;and persons authorized by lawYou have the right to request access to the personal information in your file and, if necessary, correct any inaccurate OF PLAN MEMBERCTGCFG eneral CLAIM SUBMISSION form (2017-01)SECTION 5 - MAILING INSTRUCTIONS (See reverse for CLAIM SUBMISSION instructions)ALL CLAIMS MUST BE RECEIVED WITHIN 12 MONTHS OF THE DATE OF SERVICE (unless otherwise stated in your benefit plan documentation). PLEASE ATTACH ALL ORIGINALDOCUMENTATION and retain copies for your files as original receipts will not be returned. Send your CLAIM to the corresponding address below (be sure to indicate the full address on theenvelope):OTHER CLAIMSDRUGVISION & ACCOMMODATIONMEDICAL ITEMSPROFESSIONAL BOX BOX BOX BOX BOX 1699 WINDSOR, ONWINDSOR, ONWINDSOR, ONWINDSOR, ONWINDSOR, ONN9A 6W1N9A 7G5N9A 7J3N9A 7B3N9A 7G6To avoid additional postage costs, please submit multiple claims in one envelope to any of the addresses listed above.

6 When in doubt, choose the "OTHERCLAIMS" SERVICE CENTRE 1-844-997-9888 or (519) 739-1133 SHIELD canada CLAIM SUBMISSION INSTRUCTIONSP lease call our Customer Service Centre at 1-844-997-9888 if you require any assistance in completing this ensure that you always provide your Green Shield canada ID Number in full, including suffix (ie. 00, 01, etc.)ALWAYS ENCLOSE THE FOLLOWING ITEMS WITH THE ABOVE CLAIM form :FOR BENEFIT TYPE (where applicable):Itemized receipts showing patient nameAudio (Hearing Aids) services & dates audiologist name & address breakdown of charges ( Acquisition cost, fee, mold)Prescription DrugsAll itemized prescription drug receipts from your note cash register receipts, credit card receipts and/or debit slips alone are pharmacy receipts are required. Please contact your pharmacy for a duplicate PRESCRIPTION drug CLAIMS ONLY:TO FACILITATE CLAIMS PROCESSING: Please note: Cash register receipts, credit card receipts and/or debit slips alone are insufficient.

7 Official pharmacy receipts are required. Original receipts must contain patient's name, date of service, Rx number, drug name, quantity dispensed and drug Identification Number (DIN) If injectable, please provide breakdown of quantity dispensed, drug cost and administration CLAIM is from OUT OF COUNTRY, please provide:Name of Country Visited _____ Currency Used _____ Name of drug _____Itemized receipts showing patient nameDurable Medical Equipment (includingprosthetics) a detailed description of the equipment name & address of supplier date & charge for each serviceSome medical equipment may require a medical referral/physician prescription and/or prior receipts showing patient nameCustom Foot Orthotics name and address of supplier charge for service casting technique date orthotics were receivedA prescription with diagnosis as well as Biomechanical Exam or Gait Analysis and a copy of the labinvoice is items are required unless otherwise specified by your plan receipts showing patient nameHospital Accommodation number of days in semi-private/private accommodation rate charged per day admission & discharge datesItemized receipts showing patient nameVision Care copy of vision prescription a breakdown of charges for lenses & frames date eyewear received or paid in fullItemized receipts showing patient nameExtended

8 Health - GENERAL a detailed description of services or supplies provider's name & address date & charge for each serviceCertain types of service or supplies may require a medical referral/physician prescription and/or Customer Service at 1-844-997-9888 for detailed claims SUBMISSION of Province/CountryCall Customer Service at 1-844-997-9888 for detailed claims SUBMISSION Duty NursingPre-approval is required for all nursing claims - call Customer Service for CLAIM SUBMISSION form (2017-01)