Sun Life Direct Billing Authorization Form

Sun Life Direct Billing Authorization Form
Consent and Authorization for Electric Claims

Submission and Assignment of Benefits Form
Improtant Note:

A portion of this section has been removed as it contained information intended for the provider. For the full details, please refer to the original Sun Life PDF at the bottom of this form.

Plan means a group benefits plan or an individual policy of insurance.

Plan Member means for group plans, the eligible member (e.g. for an employer group plan, this is the employee) responsible for the group benefits coverage. For individual insurance policies, the Plan Member is the policyholder. Plan Members' dependents are eligible for coverage. Dependents are the Plan Member's spouse or children.

Plan Sponsor is the policyholder of an insured or self-insured group benefits plan. For example, for Plans covering employees, the Plan Sponsor is the Plan Member's employer.

Provider refers to licensed or qualified paramedical practitioner, ophthalmologist or optometrist providing medical services or goods.

A Provider may be:

• an organization, such as a facility or clinic, submitting claims on behalf of one or more healthcare practitioners; or

• an individual responsible for their own billing.

In the Sun Life Electronic Claims Submission Agreement, we refer to the above as a Healthcare Practice and Independent Healthcare Provider respectively.
1. Plan Member Information
Name*

First nameLast name
Address*

Street number and name

Apartment or suite

CityProvince

Postal code
Phone number*
Please enter a valid phone number.
Email address*
example@example.com
Date of birth*

MonthDayYear
Date
Plan/Contract number*
(from member ID card)
Member ID*
(from member ID card)
2. Patient or Customer Information (complete this if the patient or customer is NOT the Plan Member)
Name

First NameLast Name
Is the patient's address the same as the Plan Member's?

YesNo
Address (if different)

Street number and name

Apartment or suite

CityProvince

Postal code
3. Provider/Facility Information
Name: Cedarwood Wellness - Eleanor Beeman, RMT (license number 010471)

Address: 128-970 Burrard St, Vancouver, BC V6Z 2R4

Phone number: 604-868-3045

Email address: bookcedarwood@gmail.com
4. Consent and Authorization for Electronic Claims Submissions
I authorize Provider to:

• electronically submit claims (eClaims) for healthcare goods, supplies or services for me or my dependent(s) to Sun Life Assurance Company of Canada (Sun Life) on my behalf and on behalf of my dependents

◦ for the purposes set out below (see The Purposes) and

◦ to the relevant parties also set out below (see Relevant Parties).

• disclose information about the e-claim (including personal health information in the Provider's files) to Sun Life. For any eClaims made on behalf of my dependents and for the purposes set out in this form, I confirm that my dependents authorized me to consent to the disclosure of their personal information to Sun Life.

The Purposes

I consent and agree that Sun Life and its reinsurers may collect, use and disclose the eClaims information to:

• adjudicate, review and audit eClaims;

• investigate any suspect claims involving potential fraud or plan abuse ("suspect claims"); and

• underwrite and administer the Plan

For suspect claims, I consent and agree that Sun Life and its reinsurers may also investigate claims to assess, detect and prevent potential fraud or plan abuse.

Relevant parties

I also consent and agree that Sun Life and its reinsurers may collect, use and disclose the eClaims information with relevant parties. These parties include persons or organizations having relevant information and a need to know about the eClaim including:

• the Provider or other health practitioners;

• clinics, facilities, hospitals or other institutions; and

• other insurers.

For suspect claims, I further consent and agree that Sun Life and its reinsurers may collect, use and disclose eClaims information with relevant parties that include:

• investigative agencies and the police

• regulatory bodies or associations

• government organizations

• medical suppliers

• other insurers

• my Plan Sponsor.

Overpayments

If there is an overpayment, I authorize:

• the recovery of the full amount of the overpayment from any amount payable to me under the Plan; and

• Sun Life to collect, use and disclose information about the eClaims with collection agencies.

General Information

I also understand that information pertaining to eClaims may be reviewed if the Plan is audited.

Any reference to Sun Life, reinsurers or the Plan Sponsor includes their agents and service providers.

A photocopy or electronic version of this authorization is as valid as the original, and remains in effect for the continued administration of the Plan.
Signature*

Clear
Print name*

First NameLast Name
Date (mm-dd-yyyy)*

MonthDayYear
Date
5. Assignment of Benefits
I assign the benefits payable for my and/or my dependents' eClaims to the Provider.

I authorize Sun Life to issue payment directly to Provider.

I understand that:

• I'm responsible for payment to Provider should Sun Life decline this eClaim.

• Sun Life is not required to accept this assignment.

• Sun Life's payment, whether to Provider or me, will discharge Sun Life's obligation under the Plan.

This Assignment will apply to all eligible eClaims Provider submits electronically on my behalf until I revoke it in writing with reasonable notice to Sun Life.

A photocopy or electronic version of this Assignment will be as valid as the original.

This Assignment may remain in effect for the continued administration of the Plan.
Signature*

Clear
Print name*

First NameLast Name
Date (mm-dd-yyyy)*

MonthDayYear
Date
6. Respecting Your Privacy
Respecting your privacy is a priority for the Sun Life group of companies. We keep in confidence personal information about you and the products and services you have with us to provide you with investment, retirement and insurance products and services to help you meet your lifetime financial objectives. To meet these objectives, we collect, use and disclose your personal information for purposes that include: underwriting; administration; claims adjudication; protecting against fraud, errors or misrepresentations; meeting legal, regulatory or contractual requirements; and we may tell you about other related products and services that we believe meet your changing needs. The only people who have access to your personal information are our employees, distribution partners such as advisors, and third-party service providers, along with our reinsurers. We will also provide access to anyone else you authorize. Sometimes, unless we are otherwise prohibited, these people may be in countries outside Canada, so your personal information may be subject to the laws of those countries. You can ask for the information in our files about you and, if necessary, ask us in writing to correct it. To find out more about our privacy practices, visit www.sunlife.ca/privacy.

Questions? Please visit www.sunlife.ca or call our toll-free number 1-800-361-6212 any business day from 8 a.m. to 8 p.m. ET.
This online form has been created as a digital version of the original Sun Life PDF. To view Sun Life's the original document, please click below.
Form Storage Authorization*

By checking this box, I authorize Cedarwood Wellness and its staff members to store this completed form on Jotform as an encrypted document.
Should be Empty:

Sun Life Direct Billing Authorization Form

1. Plan Member Information

2. Patient or Customer Information (complete this if the patient or customer is NOT the Plan Member)

3. Provider/Facility Information

4. Consent and Authorization for Electronic Claims Submissions

5. Assignment of Benefits

6. Respecting Your Privacy