ࡱ> 68345@ оbjbjFF 4,,v bbbbbbb$---P-/1T ;4<<<M>E??H.000Jz$R3hƖbD >@M>DDƖbb<<bbbDb<b<.bD.bbBbb<1 2X-HLT^"҃\ 0S6Dbbbbb8@)AbAB=@@@ƖƖ$(-Z6-Inpatriate/Expatriate Medical & Extended Health Claim FormPlease answer all questions fully it helps us to provide better service. All questions can be completed in ink (please print), however, the form must be signed and dated by ALL parties. Emailed, faxed or photocopied forms (once completed) are unacceptable for claims purposes.Instructions to Insured: 1. Complete the Insureds Statement Section and the Extended Health Claim Section on Page 2. 2. Have your Physician complete the Attending Physician Statement Section if the claim is over $500.00. 3. Return the ORIGINAL form, completed and signed, directly to AXA Assurances Inc. at any of the following addresses: 1075 Bay Street, Toronto, Ontario M5S 2W5 2020 University Street, Suite 700, Montreal, Quebec H3A 2A5 645 7th Avenue S.W., Suite 1400, Calgary, Alberta T2P 4G8 4. Please retain copies of receipts for your files, as originals will not be returned.Insureds Statement Section (to be completed in full by the Claimant)Policy Number: FORMTEXT      1. Insured s Full Name FORMTEXT      Date of Birth D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     2. Dependent s Full Name (if applicable)Relationship to Insured/EmployeeDate of Birth FORMTEXT       FORMTEXT       D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT      FORMTEXT       FORMTEXT       D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     (if space is insufficient, please use a separate sheet of paper)3. Name and address of post-secondary school he/she is currently attending if dependent child is age 21 or older. FORMTEXT       Please include Proof of Registration/Enrollment4. Complete Address in Canada FORMTEXT      Number & Street City Province Postal Code 5. Complete Address outside Canada FORMTEXT      6. Email Address (if applicable) FORMTEXT      7. If Expatriate  indicate date of departure from place of posting D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT      expected date of return to place of posting  D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     8. Are you or your dependents eligible for benefits under a Provincial Health Plan?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Any other medical plan?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If  Yes , please complete the following Name of eligible family member? FORMTEXT      Relationship? FORMTEXT       Name of Insurance Company administering the Plan FORMTEXT       Policy Number FORMTEXT      Type of Coverage FORMTEXT      9. Please provide the following information if you would like your claim payment deposited to a Canadian bank account: Bank # FORMTEXT      Transit # FORMTEXT      Account # FORMTEXT      Please attach a  Void chequeAssignment(To be completed by the employee if cheque is to be made payable to the Provider). This assignment is limited to physicians and hospitals for payment over $500.00. I hereby assign to  FORMTEXT       benefits payable to me, but not to exceed the charge for the services described on this claim form. I understand that I am financially responsible for charges not covered by this assignment. I certify to the best of my knowledge that the statements made are true, correct and complete.D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     (  FORMTEXT     )  FORMTEXT      Signature of Insured EmployeeDateTelephone NumberPlease return completed claim form with the  Consent to collect, use and disclose personal information form. Extended Health Claim Section (to be completed by the Claimant)Policy Number: FORMTEXT      Instructions: All claims must be accompanied by the original receipts, itemized statements or invoices; treatment and diagnosis must be included. Photocopies will not be accepted. If space is insufficient, please use a separate sheet of paper. 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Diagnosis (describe complications, if any) and Procedures   FORMTEXT      2. When did the patient first consult you for this condition? D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     3. To the best of your knowledge, when did the symptoms first appear or accident happen? D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     4. Has patient ever had same or similar condition?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If  Yes , approximate date(s) of treatment for such conditionD  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     State particulars of treatment FORMTEXT      5. Describe any other disease or infirmity affecting the patient s present condition  FORMTEXT      6. Is the condition due to pregnancy? FORMCHECKBOX  Yes  FORMCHECKBOX  No7. If Yes, what was the approximate date of commencement of pregnancy?D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     8. Was the patient hospitalized? FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, FromD  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     ToD  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     9. Name and address of hospital FORMTEXT      10. If an operation was performed, state the nature of the operation FORMTEXT      11. Date Performed D  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     12. By Doctor FORMTEXT      13. Physician s Name (please print) FORMTEXT      Physician s Signature Address  FORMTEXT       Street City Province Postal Code Telephone(  FORMTEXT     )  FORMTEXT      DateD  FORMTEXT    M  FORMTEXT    Y  FORMTEXT     The patient is responsible for securing the Attending Physician s Statement and for any charges made for its completion. 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