Get F54 371a

The F54 371a form is essential for submitting medical expense claims to your group insurance provider. This guide will help you fill out the form accurately and efficiently.

Follow the steps to complete the F54 371a form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your insurance policy number in the designated field.
3. Fill in the policyholder’s name clearly in the specified area.
4. Input the member's last name and first name as required.
5. Enter the certificate number associated with the insurance policy.
6. Provide your date of birth in the format requested.
7. Indicate your sex by selecting the appropriate checkbox.
8. Choose your preferred language by checking either English or French.
9. In the coordination of benefits section, specify if you or your dependents are covered by another group plan, and provide details if applicable.
10. List the name of the insurance company along with the policy number and coverage type.
11. Provide details of any spouse or child included in this claim, along with their dates of birth.
12. Attach original receipts for medical expenses incurred and make a note for tax purposes.
13. Complete sections regarding medical expenses for children aged 18 and over.
14. If applicable, note any expenses resulting from an accident and describe the nature and date of the accident.
15. Fill out the ambulance transportation fees section with details of the service.
16. Confirm any medical expenses incurred outside the province and follow up with any additional necessary forms.
17. Read and acknowledge the member confirmation and authorization section, ensuring that all information is accurate.
18. Sign and date the form, providing your address and contact information.

Complete your F54 371a form online for a smoother claims process.