MB BLUE CROSS HEALTH BENEFITS CLAIM FORM

HEALTH BENEFITS CLAIM FORM
PLEASE READ CAREFULLY BEFORE COMPLETING THE CLAIM. FAMILY MEMBERS MAY SUBMIT A COMBINED CLAIM.

PLEASE ATTACH ITEMIZED RECEIPTS/INVOICES AND PRESCRIPTIONS/REFERRALS (IF REQUIRED A COPY OF A VALID PRESCRIPTION IS REQUIRED FOR VISION CLAIMS. RECEIPTS WILL NOT BE RETURNED. CLAIMS MUST BE SUBMITTED WITHIN TWO YEARS OF DATE OF SERVICE, UNLESS OTHERWISE SPECIFIED IN POLICY PROVISIONS.
MEMBER INFORMATION
Certificate Number Client Number
Some plans require address changes be requested through the employer only.
Some plans require address changes be requested through the employer only.

Has your address changed? Yes qNo q
Last Name First Name

Are any expenses the result of an accident?
Yes q
No

Yes qq If Yes, please complete the following:
q If Yes, please complete the following:
Address
Work
Work

q Vehicleq Otherq
q
City Province Postal Code
City Province Postal Code
Accident details: (if extra space is required, attach an additional page)
Accident details: (if extra space is required, attach an additional page)
SERVICE RECIPIENT INFORMATION
SERVICE RECIPIENT INFORMATION
For additional service recipients, please use another claim form.

COORDINATION OF BENEFITS

	Service Recipient’s Name	Birth Date (dd/mm/yyyy)	Relationship to Member	Total Amount Claimed ($)

COORDINATION OF BENEFITS

A. Are any benefits provided under another Manitoba Blue Cross Plan? Yes qNo qIf yes, please provide the certificate number of the other plan
If yes, please provide the certificate number of the other plan

No qB. Are any benefits provided under any other insurance carrier Yes q If yes, please provide the following information:
B. Are any benefits provided under any other insurance carrier Yes q If yes, please provide the following information:
Name of the other insurance carrier
Policyholder name
Effective date of coverage

MonthDayYear
Date
Are all family members covered under this policy?
If no, please indicate which members are covered
What coverage does the other plan provide?
q

AmbulanceDentalqHospitalPrescription DrugsVision HSAq
COMPLETE THIS SECTION ONLY IF PAYMENT IS TO BE MADE TO THE SERVICE PROVIDER
Provider Number
Provider Name
City & Province
City & Province
Postal Code
HEALTH SPENDING ACCOUNT (if applicable)
Check here if you would like to request any unpaid balances from this claim to be paid using your Health Spending Account

q You must claim all medical expenses through your provincial and group insurance plans before payment can be made from a Health Spending Account. Only medical expenses recognized by Canada Revenue Agency are eligible, and payments will only be issued to the member.q I have read and understood the Authorization & Consent on the reverse side of this claim form. I confirm this claim is true and correct and that the service recipient is eligible for coverage per the agreement in place. I understand that the charges listed may not be covered by or may exceed my policy benefits. I understand that I am financially responsible to the provider for the cost of the treatments
AUTHORIZATION AND CONSENT
Member or Service Recipient Signature (or Parent/Guardian)

Clear
Date

MonthDayYear
Date
Please see reverse for contact information and how to submit your claim.
Received Date

MonthDayYear
Date
AUTHORIZATION & CONSENT
I understand that the personal information provided herein as well as any other personal information currently held or collected in the future by Manitoba Blue Cross may be collected, used, or disclosed to administer the terms of the group policy of which I am an eligible member, to develop and recommend suitable products and services to me, and to manage the company’s business. Depending on the type of coverage I carry, limited personal information may be collected from and/or released to a third party. These third parties include other Blue Cross Plans, health care professionals or institutions, health and life insurers, government and regulatory authorities, and other third parties when required to ad minister the benefits outlined in my policy or the group policy of which I am an eligible member. I understand that Blue Cross may retain service providers inside and outside of Canada to assist them in their business and further understand that my personal information may be subject to disclosure to law enforcement and other au thorities, where required by law, both inside and outside of Canada, when such information is in the possession of Blue Cross or one of its authorized service providers. I understand that I have provided my consent for Blue Cross to collect, use and disclose my personal informa tion as outlined in the Blue Cross Privacy Code. I understand that I may revoke my consent at any time; how ever, if consent is withheld or revoked, the coverage may be denied or rescinded. I understand why my personal information is needed and am aware of the risks and benefits of consenting or refusing to consent to its disclosure. For additional information regarding Manitoba Blue Cross’s privacy poli cies I can contact Manitoba Blue Cross at 204.775.0151 or 1.800.873.2583 or mb.bluecross.ca should I have questions as to the collection, use or disclosure of my personal information. I authorize Manitoba Blue Cross to collect, use and disclose my personal information as described above.
HOW TO SUBMIT YOUR CLAIM
Go paperless! Submit claims online or by mobile Mail: app for vision, prescription drug and health services. Winnipeg MB R3C 2X7

599 Empress Street Winnipeg, MB

Online: Register for mybluecross® at mb.bluecross.ca

Mobile: Download the mybluecross mobile app from Google Play or the App Store
CONTACT INFORMATION
PO Box 1046 Stn Main Winnipeg MB R3C 2X7

Email: info@mb.bluecross.ca for general inquiries

In Person: Winnipeg MB

Tuesday to Friday 10:00 a.m. to 4:00 p.m.

204.775.0151 in Winnipeg 1.800.873.2583 in Manitoba 1.888.596.1032 outside Manitoba Monday to Friday 8:00 a.m. to 5:30 p.m.

®*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, independently licensed by Manitoba Blue Cross. †Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association.
Should be Empty:

HEALTH BENEFITS CLAIM FORM

MEMBER INFORMATION

COMPLETE THIS SECTION ONLY IF PAYMENT IS TO BE MADE TO THE SERVICE PROVIDER

AUTHORIZATION AND CONSENT

AUTHORIZATION & CONSENT

HOW TO SUBMIT YOUR CLAIM

CONTACT INFORMATION