Public Service Health Care Plan (PSHCP) Claim Form

For HO use only:
HCF
Page 2 of 2
EHC-55555-E-09-10 (G3589-E)
To print a new claim form, or use the online version, visit
www.pshcp.ca
or
www.sunlife.ca/pshcp
.
Interested in receiving your payment via direct deposit?
Want to know the status of your claim?
Other questions?
5
I
Authorization and signature
By signing below, I certify that all goods and/or services being claimed have been received by me, my
spouse or my eligible dependant children. I certify that, to the best of my knowledge, the information
in this form is true and complete and does not contain a claim for any expense previously paid for by
this or any other plan. I also certify that all claimants on this form continue to meet the plan eligibility
requirements. I acknowledge and agree that the terms of my Positive Enrolment “Consent to release of
personal information” apply to this claim.
I hereby authorize Sun Life, its agents and service providers to collect, use and disclose information
about me, my spouse and my dependants to other persons and organizations including health
professionals who have, or require, relevant personal information about me, my spouse and my
dependants pertaining to this claim for the purposes of administration, audit, paying claims and
patient safety.
Member signature
X
Date (yyyy-mm-dd)
Keeping your information confidential
At all times, the information collected will be protected under the provisions of the Personal Information
Protection and Electronic Documents Act (PIPEDA).
Mailing instructions
keep a copy of this form for your records
Keep a copy of your
claim form and
receipts for your
records, since
Sun Life will not
return the originals.
Sun Life Assurance Company of Canada
PO Box 9601, CSC-T
Ottawa ON K1G 6A1
For assistance call the Sun Life PSHCP call centre at (613) 247-5100 / 1-888-757-7427
Monday to Friday, 6:30 a.m. to 8:00 p.m. EST
Definition of spouse:
A spouse means the
person who is legally
married to the member,
or a person with whom
the member has lived
for a continuous period
of at least one year,
whom the member has
publicly represented
to be their spouse and
continues to live with
as if that person were
their spouse, as desig-
nated by the member.
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Public Service Health Care Plan (PSHCP) Claim Form PDF

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