CALGARY DISTRICT PIPE TRADES HEALTH & WELFARE PLAN
HEALTHCARE EXPENSES STATEMENT
INSTRUCTIONS: Attach the bills and receipts for all expenses and itemize them by providing all the information requested.
Note: Drug bills and receipts, other than those required for government drug plans, are part of the Plan’s
records and will not be returned. Therefore, please retain copies for your own use and keep the itemization
of expenses that will accompany your payment.
IMPORTANT: Please answer all questions. This claim will be returned to you if it is incomplete or contains errors. The
processing of your claim may be delayed if you have not completed an up-to-date plan enrolment card.
POSSESSION OF THIS CLAIM FORM DOES NOT CONFER ELIGIBILITY FOR BENEFITS.
SOCIAL INSURANCE NUMBER NAME DATE OF BIRTH
ADDRESS: NUMBER AND STREET TOWN PROVINCE POSTAL CODE HOME PHONE NUMBER
COORDINATION OF BENEFITS SEND THIS CLAIM TO:
Are you or any other member of your family entitled to benefits under any other plan? Calgary District Pipe Trades
Yes □ No □ Health & Welfare Plan
If “Yes”, name the family member covered Suite 110, 2635 37 Ave. NE
Calgary, AB T1Y 5Z6
Relationship to Member
Name of other insurance company or plan
Is any member of your family (other than yourself) insured as a Member under this plan? Fax: 403-235-4377
Yes □ No □
If “Yes” to either question above, and the patient is a dependent child, please provide spouse’s date of birth: / .
Is treatment required as the result of an accident? If “Yes”, give date, location
Yes □ No □
and explain how accident happened
Is a claim being made for Worker’s Compensation Benefits?
Yes □ No □
DEPENDENT INFORMATION (If claim is for Dependent.) If child over 18 years
Date of Birth Does patient Full-Time If Student, how Employed? How many hrs
Relationship reside with you? Student? many hours per worked per
Patient Name to Member Day Month Year Yes No Yes No week? Yes No week?
Service Date* Type of Service, Drug Name or DIN… If Vision Fee Charged or Amount Reimbursed by Remaining Balance
DD MM YY Claim, attach proof of prescription change Drug Cost another Benefit Plan to be Reimbursed
(If additional space is needed, attach separate page)
I hereby authorize the use of my Social Insurance Number as an identification number where it is required in the administration of my benefits. I authorize release of any
information or record requested in respect of this claim and certify that the information given is true, correct and complete to the best of my knowledge. Personal information
will be kept confidential and will only be used to determine your entitlement to benefits under this Plan.
SIGNATURE OF MEMBER DATE
*Please note that expenses will only be reimbursed if the claim is received by the CDPT Administrator within 18 months of the service date.