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The Manufacturers Life Insurance Company Page 1 of 2 GL3655E 11/2006 CII 5 Equipment and appliance For equipment and appliance expenses Manulife Financial requires a written recommendation from the prescribing physician including diagnosis and a copy of the provincial plan statement of payment if applicable.

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How to fill out the Gl3655e Form online

Filling out the Gl3655e Form online is a straightforward process that enables plan members to submit their health care claims efficiently. This guide will walk you through each section of the form, offering clear instructions to ensure your submission is accurate and complete.

Follow the steps to fill out the Gl3655e Form online effectively

  1. Click ‘Get Form’ button to obtain the Gl3655e Form and open it in the editor.
  2. Begin by filling out the plan member information section, which includes details such as the plan contract number, certificate number, and personal identification. Ensure that the name, birthdate, address, city or town, province, and postal code are accurately entered.
  3. Indicate whether the expenses are eligible for coverage under a workers' compensation board, selecting 'Yes' or 'No.' If applicable, provide your spouse's date of birth and any other health coverage details.
  4. In the patient information section, enter the details for each patient covered under the claim using separate lines. Include the patient’s name, birthdate, relationship to the plan member, and educational status if they are a student aged 18 or older.
  5. For prescription drug expenses, attach your prescription receipts to the back of the form. Receipts must include the Drug Identification Number (D.I.N.) and the name of the medication.
  6. Complete the practitioner’s or paramedical expenses section by attaching an itemized statement or receipt that outlines the services provided, including practitioner's details and treatment costs.
  7. For equipment and appliance expenses, ensure you attach written recommendations and necessary documentation confirming the need for the item.
  8. Fill out the vision care expenses section by including an itemized receipt indicating all related costs such as glasses, eye exams, and any prescribed contact lenses.
  9. Confirm the claims information, ensuring you have signed and dated the form. This section requires your certification that all information is accurate.
  10. Finally, save the document, download it for your records, and prepare it for submission. You can print it or share it as needed, ensuring all original receipts are attached.

Complete your Gl3655e Form online today to streamline your health care claims.

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Doing a reimbursement form involves gathering your expenses and documenting them accurately. List each expense with clear descriptions and attach supporting documents. The Gl3655e Form offers a structured approach, which can effectively streamline your reimbursement process.

To fill out a reimbursement claim form, gather your receipts and enter relevant information about each expense. Use clear categories to organize your claims. The Gl3655e Form will guide you through the required details, ensuring all your submissions meet the necessary standards.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232