Get Declaration Of Hospital Insurance Coverage. This Form Is Used By Out Of Province Patients.

Filling out the Declaration Of Hospital Insurance Coverage is essential for out-of-province patients seeking insured hospital services. This guide offers step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to effectively complete the form.

1. To begin, click ‘Get Form’ button to access the document and open it for editing.
2. Provide your personal identification details as per your health insurance card. Fill in the surname, given name(s), initials, province of coverage, date of birth (year, month, day), and your health insurance number.
3. Enter your registered address with the province of coverage, including the R.R #, number and street, apartment number (if applicable), and city, town, or village, along with the postal code.
4. Indicate your gender by selecting either 'Female' or 'Male.' Along with this, input the current telephone number.
5. If you are temporarily present in the host province, provide the temporary address, including the R.R #, number and street, apartment number, city, province, and postal code.
6. Outline the reason for your entitlement to insured in-patient hospital services from the province of coverage. Select from options such as vacation/in transit, study (and provide the name of the educational institution), medical referral, temporary employment/business, other (please specify), or awaiting eligibility for coverage in another province.
7. Indicate the anticipated duration of stay by providing the start (from year, month) and end (to year, month, day) dates.
8. If applicable, fill out your permanent address in the host province, last address in your former province, and former telephone number.
9. Enter the date of departure from the province of coverage and the province of arrival.
10. Finalize the form by signing the declaration to confirm your entitlement to insured hospital services. If you are completing this on behalf of another person, please provide your name and relationship to the patient.
11. After completing the form, you may choose to save changes, download, print, or share the document for submission.

For more assistance, consider completing your documents online.