P.O. BOX 1623 WINDSOR, ONTARIO N9A 7B3 Attn: EHS Department Customer Service Centre 1-888-711-1119 or (519) 739-1133 Fax (519) 739-0046 Email: medical.authorization greenshield.ca AUTHORIZATION FORM.
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How to fill out the AUTHORIZATION FORM FOR CUSTOM BRACES - Green Shield online
This guide provides clear and comprehensive instructions on how to fill out the authorization form for custom braces through Green Shield. Follow these steps to ensure your application is completed accurately and efficiently.
Follow the steps to complete your authorization form online.
- Click ‘Get Form’ button to access the authorization form for custom braces and open it in your preferred document editor.
- In Section I, complete all required fields. Start by entering the patient's name, date of birth, and address. Ensure you include the Green Shield I.D. number, age, and contact details such as telephone number and email address. Indicate if there is other group insurance coverage by selecting ‘Yes’ or ‘No’, and provide the name of the insurance company if you answered 'Yes'.
- In Section II, this section must be filled out by the treating physician. The physician should prescribe the custom brace and include any available specifications. Specify the type of brace needed, whether it's for the left, right, or bilateral use, and provide the estimated cost.
- The physician needs to describe the patient's condition, the duration of need, and any specific diagnosis. This includes detailing past treatments and the reasons a custom brace is medically necessary.
- In continuation of Section II, the physician must indicate if the brace has been shown to the patient, whether it is a replacement item, and if there has been an application for government funding.
- The physician should also specify if the device is required due to a work-related injury, motor vehicle accident, or for sports purposes, and complete the signature along with the physician's name and telephone number.
- Review the entire form for completeness and accuracy. It is important to ensure that all fields are filled, and required signatures are included.
- Finally, save the changes you made to the form. You can download, print, or share the document as needed to submit your application.
Complete your authorization form online today for a smooth submission process.
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