Your Name
Date of birth
MM
/
DD
/
YYYY
Policy Number
Telephone Number
Email address
Address
Date of Emergency
Nature of medical emergency
Family doctor(s) in home country: Name /Phone Number/ Location
Medical expenses
Clear choice
YES I incurred out of pocket expenses
NO I did not incur out of pocket expenses
If claim is payable, please indicate who is receiving the funds
Please select
Policy Holder
Other - please indicate authorized recipient below
Please select
If other was selected above please provide the name of the recipient.
Please note that the full name is required
Medical expense list
Please provide your out of pocket expenses, date, and amounts.
Self pay reimbursment
How would you like you eligible reimbursment to be sent to you?
Please select
Cheque
Etransfer
Wire transfer
Please select
Address for reimbursment by cheque:
Etransfer email or wire transfer details:
Are you entitled to benefits under any other plan for the medical expenses being claimed?
Please select
Yes
No
Please select
Insurance company name and policy number
If answered YES to question above
Do you have a credit card with travel insurence
Please select
YES
NO
Please select
Credit card type
If answered YES to question above
Please select
Mastercard
Visa
Amex
Please select
Name on card, number and expiry date
Proof of travel
Proof of travel can include travel itinerary, boarding passes or passport stamp
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Attach medical documents,
Use this section to provide any and all medical documentation details that were provided to you regarding your medical emergency.
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Invoices, proof or payment credit card receipts or statements
Proof of payment can include credit card receipt or statement.
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This section provides Penfield authorization to obtain, recover and forward information, payments and/or obtain recovery from your Provincial health insurance plan
1. Direction and release I, the policy holder personally or as the authorized substitute/proxy for (the insured patient) Irrevocably direct and authorize the Provincial Ministry of health and long-term care (The Ministry) to make payment in respect of my claim, or if applicable the insured patient’s claim, for out of country or out of province health services directly to Penfield Care Inc and hereby release the ministry, upon payment to Penfield Care Inc., from any further claim or cause of action in connection therewith. Note: An authorized substitute/proxy is a person authorized under PHIPA to consent on behalf of an individual to disclose personal health information about the individual.
2. Consent I authorize the ministry to collect my/the insured patient’s personal health information, consisting of:
● Information relating to my/the insured patient’s receipt of health care services within or outside Canada and
● Information relevant to the reimbursement of those services under the health insurance Act and authorize the Ministry to disclose such personal health information as may be required for the purpose of verifying my/the insured patient’s request for payment under the health insurance act. Including the details of any duplicate payment previously made to me/the insured patient, to Penfield Care Inc. I understand the purpose for the Ministry’s collection and disclosure of their personal health information.
You have the right to refuse to sign this consent form, however, Penfield Care Inc and the Ministry will be unable to process your/the insured patient’s claim if this form is unsigned.
Authorized Signature
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Verification
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