EMERGENCY TRAVEL MEDICAL CLAIM FORM

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1 EMERGENCY TRAVEL MEDICAL CLAIM FORM The attached claim form must be completed in full, signed, and returned to our office as soon as possible. The receipt of your completed forms will enable us to begin the assessment of your claim. HOW TO COMPLETE YOUR EMERGENCY HOSPITAL & MEDICAL INSURANCE CLAIM FOR CANADIANS SECTION A CLAIMANT INFORMATION This section allows us to verify the claimant and policy information. If you contacted ACM to initiate your case, much of this section will be pre-populated. If necessary, please correct any inaccurate fields so that we may update our records. Departure Date Section This section is required to verify that your trip and medical emergency fell within the effective date of your policy. If you have an annual policy plan, you must include proof of departure from your province of residence. The type of proof depends on whether you traveled by airline or car. Any one of the documents listed below are accepted as proof of departure: - Airline tickets/boarding passes - Travel Itinerary - Original gas receipts - Original hotel receipts - Original meal receipts - Toll highway receipts SECTION B OTHER EMERGENCY MEDICAL INSURANCE COVERAGE This section allows us to coordinate medical payments with any other insurance plans that you may have in addition to this plan. Complete Section B if you have other out of province travel insurance such as a group policy through work or coverage through a credit card. If you do not have other insurance, indicate this by selecting the option I do not have any other out of province medical insurance coverage. SECTION C MEDICAL INFORMATION This section provides a brief synopsis of the medical situation incurred which allows us to verify the information already on file when the case initiated. If you were hurt, fill out the Injury section. If you were sick, fill out the Sickness section. SECTION D CERTIFICATION & AUTHORIZATION This section must be completed in order to release payment of your claim. Completion certifies that the information provided in connection with this claim is complete, true and accurate. This signed release allows us to access your personal medical information that is related to the claim. When determined applicable, it also allows us to obtain your past medical history from your treating providers in Canada in order to verify eligibility and stability requirements outlined in accordance to your policy. PROVINCIAL HEALTH INSURANCE PLAN AUTHORIZATION FORM This section allows us to submit to your Provincial Health Plan or other Insurance plans for eligible medical expenses ACM pays on your behalf. Residents of British Columbia must also complete the Schedule A enclosed with these forms. Active Care Management P.O. Box 1237 Station A Windsor, ON N9A 6P8 Form 100 A

2 REQUIRED ATTACHMENTS To process your claim, the following documents should be sent with your forms (please do not staple documents together); If you paid any expenses yourself, please provide proof of payment by sending original bills and receipts. Please fill out the Expense Sheet attached. Please note, cash register receipts, credit card receipts and/or debit slips alone are insufficient. FOR PRESCRIPTION DRUGS: Official pharmacy receipts are required which must contain patient s name, date of service, drug name, quantity dispensed. All medical records, documents & certificates, provided at the time of treatment. This includes a diagnosis report, list of medication given and type of treatment provided. For example: a copy of the Emergency Room (ER) report, clinical documentation or a written letter from the doctor you saw. If you were hospitalized, we require a copy of your medical records from the treatment facility you attended. If you have any additional information about your claim, please submit. SUBMITTING YOUR CLAIM By Mail: All original forms, along with all documents noted above can be sent to our claims office: Canadian Mailing Address Active Care Management P.O. Box 1237 Station A Windsor, ON N9A 6P8 U.S.A. Mailing Address Active Care Management 535 Griswold Ave. Ste Detroit, MI Please save copies of all original claim forms, receipts and supporting documentation. ACM reserves the right to request original documentation when necessary to adjudicate your claim. WHAT TO EXPECT DURING THE CLAIMS PROCESS Once your completed claim package is received, your claim will go through the following stages: 1. Initial Review Your documentation will be reviewed by our team for completeness and accuracy. This means we will be checking to ensure all the required documentation mentioned above is included with your claim form. If required documentation is missing, you will be notified by ACM. When all required documentation is received, your claim will be assigned to a Claim Adjudicator who will begin the Evidence Review Stage. Tip: Ensure that all sections of your claim form are fully completed, signed and dated. Submitting a complete claims package will ensure your claim is expedited through the Initial Review stage. 2. Evidence Review During this stage, the Claim Adjudicator will review the details of the claim and identify if a decision can be made or if further clarification and collection of information is required. It is during this stage that past medical history, treatment notes or additional supporting evidence may be obtained. When all evidence is obtained, the claim will progress to the Decision Stage. Tip: You will be notified within 30 days if additional evidence is required. 3. Decision Stage Once at this stage, the Claim Adjudicator will review all information collected, assess the claim under the insurance policy s terms and conditions and make a decision. For approved claims, you will be notified of the decision by receiving a cheque with an explanation of benefits. When a claim is denied, you will receive written correspondence from ACM. Payments by cheque are issued within three business days of approval decision and sent by standard Canadian mail. Active Care Management P.O. Box 1237 Station A Windsor, ON N9A 6P8 Form 100 A

3 EMERGENCY TRAVEL MEDICAL CLAIM FORM Send your completed form to: [CANADA] Active Care Management, P.O. Box 1237, Station A, Windsor, ON N9A 6P8 [U.S.A] Active Care Management, 535 Griswold Ave., Ste , Detroit, MI IMPORTANT: This claim form must be completed in full, signed, and returned to our office. The receipt of your completed forms will initiate the claims review process. The Authorization section must be completed in order to process your claim. By signing and submitting this form you certify that the information provided in connection with this claim is complete, true and accurate. SECTION A CLAIMANT INFORMATION Claimant s Name (Last Name, First Name, Middle Initial) Date of Birth Policy Number Gender Male Female Home Address City Province Postal Code Address Travel Destination Departure Date Fax Return Date SECTION B OTHER EMERGENCY MEDICAL INSURANCE COVERAGE Do You and/or Your Spouse or Child Have Other Emergency Medical Insurance Benefits? (Check all that apply) Employer Retiree Plan Home/Auto Other I do not have any other out of province medical insurance coverage. Plan Name of Insurance Company Group Policy # Member ID # # Your Employer Your Spouse s Employer Name of Spouse (last name, first name): Retiree Plan Other Coverage Signature of Policyholder of other coverage Do you have credit card insurance coverage for out-of-province travel?, If yes, provide: Date of Birth Name of Issuing Bank for Credit Card: Name of Cardholder Credit Card # Date of Expiry Signature of Cardholder (if different from insured) Date Signed Does this claim relate to a Motor Vehicle Accident? Name of Motor Vehicle Insurance Company Policy # Address City Province Postal Code ACM is committed to protecting the privacy, confidentiality and security of the personal information we collect, use and disclose. Your personal information will be used only for the purpose of providing you with the requested insurance services. For a copy of ACM s privacy policy, please contact us. Active Care Management P.O. Box 1237 Station A Windsor Ontario N9A 6P8

4 EMERGENCY TRAVEL MEDICAL CLAIM FORM SECTION C MEDICAL INFORMATION Please list the name and telephone number of your Family Physician as well as any Specialists that you have been or are currently seen by. Name of Usual Canadian Physician (Family Doctor) Physician s Name & Specialty Physician s Name & Specialty Was this condition related to a Pregnancy?, If, Expected Date of Delivery Injury Is this claim the result of an Injury? Brief Description of Injury and Diagnosis Date of Injury Sickness Date Symptoms first appeared Treating Doctor s Name First date of Treatment List names of any Medications you were taking prior to visiting the Doctor: Diagnosis Have you ever experienced this sickness or a similar problem before? Do you have any Chronic Sickness or Disease? Describe Conditions / Diagnosis: Date of Previous Occurrence Date Diagnosed SECTION D CERTIFICATION & AUTHORIZATION Signature required below. The insurer, its agents and administrators are obliged to collect and retain certain personal and/or health information about you in connection with your insurance coverage. They use and disclose that information only for the purposes of administering your policy/policies of insurance, providing customer service and assessing and paying claims. I/We authorize any licensed physician, medical practitioner, hospital, clinic, other medical facility or provider of health care, insurer or reinsurer, provincial health insurance plan and employer(s) to provide Active Care Management (ACM), and its representatives employed to assist in the administration of this claim, any information, including personal information, data or records t hat are in their possession/knowledge regarding my medical history and treatment. I/We direct and authorize my Government Health Insurance Plan (GHIP) to make payment in respect of my claim for out of country Health services to ACM, directly and I hereby release GHIP, upon payment to ACM from any further claim or cause of action in connection herewith. I hereby consent and authorize GHIP to directly or indirectly collect information contained in the claim and source documents pursuant to the freedom of information and protection of privacy act, and the Health Insurance Act. I/We authorize ACM to coordinate the payment of benefits with any other insurance carriers which may also have a liability for this claim. I/We hereby irrevocably direct ACM to make any payments, receive payments and settle with other carriers on my/our behalf. I hereby consent to the use of ACM, the insurers its agents and administrators of the personal and health information about me disclosed herein and in all documents or information provided in connection with my policy/policies of insurance for purposes cited above. A photocopy of this authorization shall be considered as effective and valid as the original. This authorization shall be considered valid for the duration of the claim, but not to exceed one year from date signed. I certify that the information provided in connection with this claim is complete, true and accurate. tice: The provincial legislation in some provinces requires us to inform you that the time limit for taking legal action is set out in the Insurance Act or other legislation that applies to your claim. Policyholder s Signature (If minor, signature of parent or legal guardian) Date Name of Patient/Insured (Last Name, First Name, Middle Initial) If you authorize payment of this claim to anyone other than yourself or your provider, please provide name of recipient: Date Date Active Care Management P.O. Box 1237 Station A Windsor Ontario N9A 6P8

5 Expense Sheet Name of Insured: Please list below any PAID out of pocket expenses. Please note, your claim will not be processed unless original documentation is supplied. If you receive additional bills after submission of this expense sheet, contact our office for additional instructions prior to making a payment. Facility Name (pharmacy, doctor, etc.) Description of Expense (prescription) Date of Service (mm/dd/yy) Amount Paid by Insured Type of Currency Date Paid (mm/dd/yy) Receipt attached (if no, please explain in comment section below) Comments (please use back of page if required) Active Care Management P.O. Box 1237 Station A Windsor, ON N9A 6P8 Form 100 A

6 GOVERNMENT HEALTH PLAN SECTION AUTHORIZATION & RELEASE RESIDENTS OF: BRITISH COLUMBIA THIS THIS SECTION MUST MUST BE BE COMPLETED PRIOR PRIOR TO TO ANY ANY MEDICAL CLAIM CLAIM PAYMENTS AUTHORIZATION TO PROVIDE MEDICAL INFORMATION ASSIGNMENT OF PAYMENT TO INSURED PERSON OR BENEFICIARY UNDER THE MEDICARE PROTECTION ACT OR HOSPITAL INSURANCE ACT BETWEEN THE MANUFACTURERS LIFE INSURANCE COMPANY C/O MANULIFE FINANCIAL. PO BOX 4906 STN A, TORONTO, ONTARIO M5W 0B4 HER MAJES TY THE QUEEN IN THE RIGHT OF THE PROVINCE OF BRITISH COLUMBIA AS REPRESENTED BY THE MINISTER OF HEALTH of the first part hereinafter referred to as the Assignor of the second part hereinafter referred to as the Assignee hereinafter referred to as the Minister WHEREAS the Assignor is a person eligible for insured services or benefits or both under the Province of British Columbia s Medicare Protection Act or Hospital Insurance Act or both, and as such may receive payment for the above services from the Minister. And WHEREAS the Assignor is under a covenant or obligation under a contract with the Assignee to remit to the Assignee all such payments received for medical services from the Minister. NOW WITNESSETH THAT in consideration of the said obligation to the Assignee the Assignor hereby assigns unto the Assignee all sums of money that shall be owing to the Assignor by the Minister for the above noted contract. The Minister is hereby authorized to pay all such sums directly to the Assignee at the address aforesaid, or at any address the Assignee may from time to time designate, with payment of any such sum to be sufficient discharge to the Minister of and from any indebtedness in that amount to the Assignor, his heirs, executors, or administrators. I HEREBY CONSENT TO AUTHORIZE THE MINISTRY OF HEALTH TO FURNISH ANY REPRESENTATIVE OF THEMANUFACTURERS LIFEINSURANCECOMPANY (MANULIFE F HAD INSURANCE COVERAGE FOR THE ASSIGNMENT PERIOD INCLUDING MEDICAL HISTORY PHYSICAL CONDITION BOTH PRIOR SUBSEQUENT TO RECEIPT OF DATED this ASSIGNMENT: EFFECTIVE FROM WITNESS SIGNATURE ADDRESS day of SIGNATURE OF ASSIGNOR D M Y D M Y TO: OCCUPATION PERSONAL HEALTHCARD NO., 20 CITY TELEPHONE PROVINCE POSTAL CODE GOVERNMENT HEALTH PLAN SECTION AUTHORIZATION & RELEASE RESIDENTS OF: SASKATCHEWAN THIS THIS SECTION MUST MUST BE BE COMPLETED PRIOR PRIOR TO TO ANY ANY MEDICAL CLAIM CLAIM PAYMENTS AUTHORIZATION TO PROVIDE MEDICAL INFORMATION ASSIGNMENT OF PAYMENT TO INSURED PERSON OR BENEFICIARY UNDER THE MEDICARE PROTECTION ACT OR HOSPITAL INSURANCE ACT BETWEEN THE MANUFACTURERS LIFE INSURANCE COMPANY C/O MANULIFE FINANCIAL PO BOX 4906 STN A, TORONTO, ONTARIO M5W 0B4 HER MAJESTY THE QUEEN IN THE RIGHT OF THE PROVINCE OF SASKATCHEWAN AS REPRESENTED BY THE MINISTER OF HEALTH of the first part hereinafter referred to as the Assignor of the second part hereinafter referred to as the Assignee hereinafter referred to as the Minister WHEREAS the Assignor is a person eligible for insured services or benefits or both under The Saskatchewan Medical Care Insurance Act or The Saskatchewan Hospitalization Act or both, and as such may receive payment for the above services from the Minister. And WHEREAS the Assignor is under a covenant or obligation under a contract with the Assignee to remit to the Assignee all such payments received for medical services from the Minister. NOW WITNESSETH THAT in consideration of the said obligation to the Assignee the Assignor hereby assigns unto the Assignee all sums of money that shall be owing to the Assignor by the Minister for the above noted contract. The Minister is hereby authorized to pay all such sums directly to the Assignee at the address aforesaid, or at any address the Assignee may from time to time designate, with payment of any such sum to be sufficient discharge to the Minister of and from any indebtedness in that amount to the Assignor, his heirs, executors, or administrators. I HEREBY CONSENT TO AUTHORIZE THE MINISTRY OF HEALTH TO FURNISH ANY REPRESENTATIVE OF THEMANUFACTURERS LIFEINSURANCECOMPANY (MANULIFE HAD INSURANCE COVERAGE FOR THE ASSIGNMENT PERIOD INCLUDING MEDICAL HISTORY PHYSICAL CONDITION BOTH PRIOR SUBSEQUENT TO RECEIPT OF DATED this ASSIGNMENT: EFFECTIVE FROM WITNESS SIGNATURE ADDRESS day of SIGNATURE OF ASSIGNOR D M Y D M Y TO: OCCUPATION PERSONAL HEALTHCARD NO., 20 CITY TELEPHONE PROVINCE POSTAL CODE

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