BRITISH COLUMBIA BCPSEA PUBLIC SCHOOL EMPLOYERS’ EHC claim form ASSOCIATION Extended Health Care Claim Form PACIFIC BLUE CROSS TM • Please read instructions on reverse before submitting this form. Ensure you have completed all sections. • Enclose all original receipts. Keep a copy of the receipts for your records. Mailing Address Street Address • Please refer to your Pacific Blue Cross EHC card for your group, ID and dependent numbers. PO Box 7000 4250 Canada Way Vancouver BC V6B 4E1 Burnaby BC • For help completing this form, or for more information on your EHC plan, call us at 604-419-2600 or 1-888-275-4672. MEMBER INFORMATION Company name Member’s last name Member’s address Group number Member’s identity number Member’s first name Postal code Daytime phone number E ( ) Member’s provincial health plan number (Care Card) Member’s E-mail address EXPENSE INFORMATION Name of dependent claiming Birth date Dependent Type of expense or name of medication Date of each purchase or service or Amount Provider/prescriber Nature of illness (list in dependent and date order) mm/dd/yy number (Example: hospital, ambulance, hospital admission and discharge dates paid of service or injury or name of clinic) mm/dd/yy My family is (or, I am) registered with Total Claim: $0.00 Fair PharmaCare Yes No Do you or your dependents have other insurance Pacific Blue Cross does not return receipts. Please save our Explanation Is your claim the result of an accident? to cover these benefits? Yes No of Benefits for income tax purposes. If you also have coverage with If yes, attach accident details. Yes No another insurance company, make a photocopy of all receipts before sending the originals to Pacific Blue Cross. Name of the other insurance company Is this a Workers’ Compensation I certify that I and/or my dependents incurred these expenses. All information (WCB) case? Yes No is correct. Group number ID number I consent to Pacific Blue Cross using this personal information to Is this an ICBC, or other adjudicate my claim and disclosing this information when required or auto insurance, case? Yes No Name of member with other insurance company permitted by law or pursuant to its contractual obligations under my Are you seeking damages benefit plan. from a third party? Yes No I also authorize Pacific Blue Cross or its agents access to any relevant Effective date mm/dd/yy Cancellation date mm/dd/yy information required to adjudicate this claim. Are any of these expenses due to a medical emergency while you were outside of the province where you live? If yes, please contact Pacific Blue Cross for an Out of Province claim form. If you are claiming for the balance not paid by the other insurance company, X include photocopies of your receipts and their payment statement. Member’s signature Date 10-60-023 03/07 CUPE 1816 Morneau Sobeco IMPORTANT CLAIMING INFORMATION prosthetic appliances, ostomy supplies.) Submit to HEARING AIDS Please provide all information requested on both Fair PharmaCare for payment by March 31st of the year following the service or purchase. When you Please check your plan brochure for any age pages of this claim form. Pacific Blue Cross is restrictions. unable to process incomplete claims. purchase prescription drugs, your pharmacist submits claims to Fair PharmaCare on your behalf. REGISTERED NURSES 1) Submit all claims with itemized statements and original paid receipts, which indicate: To claim for the benefits listed below, see the Along with your receipts, Pacific Blue Cross specific instructions. requires a letter from the attending doctor, • patient’s name Check your plan brochure for a list of eligible indicating the diagnosis, that he or she ordered • type of purchase or service benefits and the conditions when these benefits the nurse’s services, and the necessity for the • date of each purchase or service services. are eligible. • amount charged for each purchase or service PRESCRIBED DRUGS ORTHOPEDIC SHOES Pacific Blue Cross is unable to accept • official PharmaCare receipt Along with your receipts, Pacific Blue Cross photocopies unless you have submitted the SERVICES (physiotherapist, chiropractor, requires a letter from the orthopedic surgeon, original receipts to your other insurance company. doctor or podiatrist, indicating the diagnosis, the If so, attach copies of your receipts and a copy of podiatrist, naturopath, massage necessity for prescribing the shoes, and the type their payment statement. practitioner) of shoes prescribed. 2) List all expenses in dependent and date • type of service order. • date of each treatment DENTAL ACCIDENTS 3) Pacific Blue Cross will only consider paying • amount charged for each treatment Along with your receipts, Pacific Blue Cross claims that exceed your deductible. See your • therapist’s name and phone number requires from the dentist a detailed list of Pacific Blue Cross EHC card or brochure for services performed. We also require the exact HOSPITAL ACCOMMODATION date of the accident, the circumstances of the information about your plan deductible. • type of room (semi-private, private) accident, and information on any other dental 4) All claims must be received in the office of • admission and discharge dates coverage. Include all relevant X-rays. Pacific Blue Cross no later than December • daily charge 31st of the year following the date of purchase THIRD PARTY LIABILITY • a description of any additional charges or service (unless otherwise agreed upon by Your EHC plan does not pay for any benefits if a your Employer). Late submissions will not be AMBULANCE third party is liable by law. For claims due to an accepted. • reason for taking the ambulance accident, indicate if there is possible third party 5) Submit your EHC claims regularly (Pacific • date of service liability. If yes, please contact Pacific Blue Cross Blue Cross suggests about every three • places ambulance taken from and to for further information, as you must complete months). Do not hold your claims until the • amount charged third party forms. claiming deadline. OUT OF PROVINCE VISION CARE Your EHC plan may include a deductible and a Not all EHC plans cover vision care benefits. reimbursement percentage (example: $25.00 MEDICAL EXPENSES Please contact your plan administrator to obtain Check your plan brochure. Submit itemized deductible, balance paid at 80%). Check your receipts, that show the purchase date and the plan brochure for details. the following forms: patient’s name. All BC residents covered by the Medical Services • MSP Out-of-Country claim form Plan of BC are eligible for Fair PharmaCare • Emergency Out-of-Province Expense claim benefits. If you have not already done so, please form register with Fair PharmaCare in order to maximize • Schedule A your financial eligibility. Expenses paid in part by Complete all necessary forms and submit to Secure online access Pacific Blue Cross may be eligible with Fair Pacific Blue Cross promptly in order that we may to benefit information for PharmaCare and should be submitted to Fair submit your claim to MSP within their 90 day Pacific Blue Cross members. PharmaCare first for their consideration. (Examples: deadline. www.pac.bluecross.ca ™ Pacific Blue Cross, the registered trade name of PBC Health Benefits Society, is an independent licensee of the Canadian Association of Blue Cross Plans.