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Get Green Shield Claim Form For Related Health Professional Services

OR RECEIPTS IF THIS FORM IS FULLY COMPLETED. THE COST, IF ANY, OF OBTAINING THIS INFORMATION IS AT THE EXPENSE OF THE PATIENT/SUBSCRIBER. ALL CLAIMS MUST BE SUBMITTED WITHIN 12 MONTHS OF THE DATE OF SERVICE. GREEN SHIELD CANADA P.O. BOX 1699, WINDSOR, ONTARIO N9A 7G6 CLAIM FORM FOR RELATED HEALTH PROFESSIONAL SRV (Rev. 2006-12) ATTENTION: EHS DEPARTMENT CUSTOMER SERVICE CENTRE 1-888-711-1119 or (519) 739-1133 PROF.

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