Follow the steps to complete your claim form effectively.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. In the 'Plan member information' section, provide your group number, firm number, certificate number, last name, first name, mailing address, city, phone number, province, and postal code. Ensure all fields are accurately filled.
3. In the 'Plan member questions' section, indicate whether you or your dependents are entitled to benefits under any other plan by checking 'Yes' or 'No'. If applicable, provide your spouse’s name, date of birth, and the name of the insuring company.
4. Answer if any of the claimed services were required due to an accident and if you are seeking damages from a third party.
5. In the 'Claimed expenses' section, list each patient’s name, date of birth, service date, service type, relationship to the plan member, and the amount claimed for each service. Ensure to include any letters of assignment from providers if benefits are assigned.
6. Complete the 'Plan member statement' by certifying that the expenses incurred are true and correct. Sign and date the document to validate your claim.
7. After filling out the form, you can save changes, download, print, or share the completed form as needed.

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