Get Green Shield Authorization Form

Filling out the Green Shield Authorization Form is a crucial step for individuals seeking approval for prosthetic appliances and durable medical equipment. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently online.

Follow the steps to complete the Green Shield Authorization Form online

1. Click 'Get Form' button to access the form and open it in your preferred editor.
2. In Section I, complete all mandatory fields as the patient or their guardian. Enter the patient's name, full address, date of birth, age, Green Shield number, telephone number, and email address. Indicate if there is any other group insurance coverage and provide the necessary details if applicable.
3. Proceed to Section II, which must be filled out by the physician. The physician should prescribe the required prosthetics appliances and/or medical equipment, including specifications when available. Enter the estimated costs for each item prescribed (A, B, C, D, E).
4. In this section, the physician must also indicate the condition of the patient, the duration of need (acute, chronic, palliative), and a detailed diagnosis.
5. If applicable, for hospital beds, provide the percentage of time the patient spends in bed. For viscosupplementation, indicate if it's for the left or right knee.
6. The physician must detail why standard items are insufficient and why a custom solution is necessary. Additionally, indicate if the prescribed item is a replacement and if government funding has been applied for.
7. Specify if the device and/or medical equipment is required due to a work-related injury, motor vehicle accident, or sports purposes.
8. Once all sections are completed and reviewed, ensure the physician signs the form, prints their name, includes their designation (G.P. or Specialist), and provides their phone number.
9. After finishing the form, save any changes. You may download, print, or share the completed form as needed to submit it to Green Shield Canada.

Start completing your Green Shield Authorization Form online today to ensure timely processing of your request.