Get Pacific First Claim Form

Completing the Pacific First Claim Form online is a straightforward process that ensures your claim for dental and healthcare benefits is properly submitted. This guide will provide you with step-by-step instructions to fill out the form accurately and efficiently.

Follow the steps to complete the Pacific First Claim Form online.

1. Click ‘Get Form’ button to obtain the claim form and open it in your preferred online editor.
2. Begin by entering your client information. Fill in the employer's name, plan number, and your name along with your date of birth in the DD/MM/YYYY format.
3. Indicate whether your address has changed in the past year by selecting 'Yes' or 'No'. If yes, provide your new address details.
4. Enter your phone number, city, province, and postal code in the appropriate fields.
5. Complete the necessary claims information. Indicate if the claim is for Worksafe BC benefits or if it’s due to an automobile accident. Provide the details regarding the accident if applicable, including date, time, and location.
6. If you, your partner, or dependent children have any other extended health insurance coverage, select 'Yes' or 'No' and provide the required details of the other insurance company, if applicable.
7. Fill in the spousal and dependent information section by listing each patient's name, relationship to you, date of birth, and specify if they reside with you. Also indicate their full-time student status and whether they are handicapped.
8. In the claim summary section, enter the patient's name, date of purchase or service, description of the service, nature of illness, and total charges. Ensure all values are correctly inputted.
9. Finally, review the authorization and consent section. Certify all information submitted is true and complete and provide your signature along with the date.
10. Once the form is completed, save your changes, download a copy for your records, and print or share the form as needed.

Ready to submit your claim? Complete the Pacific First Claim Form online today.