Public Service Health Care Plan (PSHCP) Claim Form
Page 1 of 2
EHC-55555-E-09-10 (G3589-E)
Public Service Health Care Plan (PSHCP)
Claim Form
PROTECTED once completed. Ce formulaire est disponible en français.
Please read all instructions and information; make sure that all sections are complete and accurate
or this claim will be returned to you.
For HO use only:
HCF
Contract number
055555
1
I
Member information
Last name First name Certificate number
Date of birth (yyyy-mm-dd)
– –
Language preference
English
French
Gender
Male
Female
Home telephone number
– –
Permanent address (street number and name) Apartment or suite
City Province/territory Postal code
Your claim will be adjudicated
based on the coordination
of benefits information you
provided about yourself and
your eligible dependants
during positive enrolment.
Any discrepancies could result
in a delay in payment.
If your spouse is a member of
another group health care
plan, he/she must submit
his/her expenses under that
plan first.
2
I
Coordination of benefits
Is your spouse a member of the PSHCP or another plan administered by
Sun Life Financial?
Yes
No If yes, provide details below.
Does your spouse authorize us to process this claim under his/her
certificate number?
Yes
No If yes, provide details below.
Last name of spouse Gender
Male
Female
Spouse’s contract number Spouse’s certificate number
Signature of spouse
X
3
I
Complete if claiming expenses for your spouse or dependant children
First name Last name Date of birth (yyyy-mm-dd) Relationship to you
– –
Spouse
Daughter
Son
Other
– –
Spouse
Daughter
Son
Other
– –
Spouse
Daughter
Son
Other
– –
Spouse
Daughter
Son
Other
Ensure that the currency and
amount are clearly marked
on each receipt. We will
convert the eligible expenses
to Canadian dollars.
Attach original receipts for
each expense claimed.
4
I
Information about your claim
Are any of the expenses the result of a work injury?
Yes
No
If yes, enclose your worker’s compensation statement.
Are any of the expenses the result of a motor vehicle accident?
Yes
No
If yes, enclose your automobile insurance plan statement.
Are any of the expenses incurred outside your province/territory of residence?
Yes
No
If yes, provide the date of departure from your home province/territory
Date (yyyy-mm-dd)
– –
Were you on government business travel?
Yes
No
Total amount submitted for this claim
$
Page 1/2
Free Download
Public Service Health Care Plan (PSHCP) Claim Form PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
