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Get Green Shield Orthotics Claim Form

Ow are mandatory in order for Green Shield to determine our liability with respect to this request. PROVIDER Provider No. PATIENT Telephone No. ( Green Shield I.D. No. Date of Birth ) / / Name Name Street Address Address City Province Postal Code City Province Postal Code Do you have any other Group Insurance coverage that may include these services as benefits? Yes No If yes, please provide Insurance Company name.

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  1. Select the orange Get Form button to start filling out.
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