EMERGENCY TRAVEL MEDICAL CLAIM FORM

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Active Care Management | P.O. Box 1237 Station A Windsor, ON N9A 6P8 | Form 100 A 07 2015

EMERGENCY TRAVEL MEDICAL CLAIM FORM

The attached claim form must be completed in full, signed, and returned to our office as soon as possible. The receipt of your completed forms will enable us to begin the assessment of your claim.

HOW TO COMPLETE YOUR EMERGENCY HOSPITAL & MEDICAL INSURANCE CLAIM FOR CANADIANS

SECTION A – CLAIMANT INFORMATION

This section allows us to verify the claimant and policy information. If you contacted ACM to initiate your case, much of this section will be pre-populated. If necessary, please correct any inaccurate fields so that we may update our records.

Departure Date Section

This section is required to verify that your trip and medical emergency fell within the effective date of your policy. If you have an annual policy plan, you must include proof of departure from your province of residence. The type of proof depends on whether you traveled by airline or car. Any one of the documents listed below are accepted as proof of departure:

- Airline tickets/boarding passes - Travel Itinerary - Original gas receipts - Original hotel receipts - Original meal receipts - Toll highway receipts

SECTION B – OTHER EMERGENCY MEDICAL INSURANCE COVERAGE

This section allows us to coordinate medical payments with any other insurance plans that you may have in addition to this plan. Complete Section B if you have other out of province travel insurance such as a group policy through work or coverage through a credit card. If you do not have other insurance, indicate this by selecting the option “I do not have any other out of province medical insurance coverage.”

SECTION C – MEDICAL INFORMATION

This section provides a brief synopsis of the medical situation incurred which allows us to verify the information already on file when the case initiated.

If you were hurt, fill out the Injury section. If you were sick, fill out the Sickness section.

SECTION D – CERTIFICATION & AUTHORIZATION

This section must be completed in order to release payment of your claim. Completion certifies that the information provided in connection with this claim is complete, true and accurate.

This signed release allows us to access your personal medical information that is related to the claim. When determined applicable, it also allows us to obtain your past medical history from your treating providers in Canada in order to verify eligibility and stability requirements outlined in accordance to your policy. PROVINCIAL HEALTH INSURANCE PLAN AUTHORIZATION FORM

This section allows us to submit to your Provincial Health Plan or other Insurance plans for eligible medical expenses ACM pays on your behalf.

Residents of British Columbia must also complete the Schedule A enclosed with these forms.

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REQUIRED ATTACHMENTS

To process your claim, the following documents should be sent with your forms (please do not staple documents together);

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If you paid any expenses yourself, please provide proof of payment by sending original bills and receipts. Please fill out the Expense Sheet attached. Please note, cash register receipts, credit card receipts and/or debit slips alone are insufficient. FOR PRESCRIPTION DRUGS: Official pharmacy receipts are required which must contain patient’s name, date of service, drug name, quantity dispensed.

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All medical records, documents & certificates, provided at the time of treatment. This includes a diagnosis report, list of medication given and type of treatment provided. For example: a copy of the Emergency Room (ER) report, clinical documentation or a written letter from the doctor you saw.

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If you were hospitalized, we require a copy of your medical records from the treatment facility you attended.

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If you have any additional information about your claim, please submit. SUBMITTING YOUR CLAIM

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By Mail: All original forms, along with all documents noted above can be sent to our claims office: Canadian Mailing Address U.S.A. Mailing Address

Active Care Management P.O. Box 1237

Station A Windsor, ON N9A 6P8

Active Care Management 535 Griswold Ave.

Ste 111-605 Detroit, MI 48226

Please save copies of all original claim forms, receipts and supporting documentation. ACM reserves the right to request original documentation when necessary to adjudicate your claim.

WHAT TO EXPECT DURING THE CLAIMS PROCESS

Once your completed claim package is received, your claim will go through the following stages: 1. Initial Review

Your documentation will be reviewed by our team for completeness and accuracy. This means we will be checking to ensure all the required documentation mentioned above is included with your claim form. If required documentation is missing, you will be notified by ACM. When all required documentation is received, your claim will be assigned to a Claim Adjudicator who will begin the Evidence Review Stage.

Tip: Ensure that all sections of your claim form are fully completed, signed and dated. Submitting a complete claims package will ensure your claim is expedited through the Initial Review stage.

2. Evidence Review

During this stage, the Claim Adjudicator will review the details of the claim and identify if a decision can be made or if further clarification and collection of information is required. It is during this stage that past medical history, treatment notes or additional supporting evidence may be obtained. When all evidence is obtained, the claim will progress to the Decision Stage.

Tip: You will be notified within 30 days if additional evidence is required. 3. Decision Stage

Once at this stage, the Claim Adjudicator will review all information collected, assess the claim under the insurance policy’s terms and conditions and make a decision. For approved claims, you will be notified of the decision by receiving a cheque with an explanation of benefits. When a claim is denied, you will receive written correspondence from ACM. Payments by cheque are issued within three business days of approval decision and sent by standard Canadian mail.

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EMERGENCY TRAVEL MEDICAL CLAIM FORM

Active Care Management | P.O. Box 1237 Station A Windsor Ontario N9A 6P8 Send your completed form to:

[CANADA] Active Care Management, P.O. Box 1237, Station A, Windsor, ON N9A 6P8 [U.S.A] Active Care Management, 535 Griswold Ave., Ste 111-605, Detroit, MI 48226

IMPORTANT: This claim form must be completed in full, signed, and returned to our office. The receipt of your completed forms will initiate the claims review process. The Authorization section must be completed in order to process your claim. By signing and submitting this form you certify that the information provided in connection with this claim is complete, true and accurate.

SECTION A – CLAIMANT INFORMATION

Claimant’s Name (Last Name, First Name, Middle Initial) Date of Birth

MM | DD | YYYY

Policy Number Gender

 Male

 Female

Home Address City Province Postal Code

Email Address Phone

( )

Fax ( )

Travel Destination Departure Date

MM | DD | YYYY

Return Date

MM | DD | YYYY

SECTION B – OTHER EMERGENCY MEDICAL INSURANCE COVERAGE

Do You and/or Your Spouse or Child Have Other Emergency Medical Insurance Benefits? (Check all that apply)

 Employer  Retiree Plan  Home/Auto  Other  I do not have any other out of province medical insurance coverage.

Plan Name of Insurance Company Group Policy # Member ID # Phone #

Your Employer Your Spouse’s Employer

Name of Spouse (last name, first name):

Retiree Plan

Other Coverage

Signature of Policyholder of other coverage Date of Birth

MM | DD | YYYY Do you have credit card insurance coverage for out-of-Province travel?  No  Yes, If yes, provide:

Name of Issuing Bank for Credit Card:

Name of Cardholder Credit Card # Date of Expiry

MM | DD | YYYY

Signature of Cardholder (if different from insured) Date Signed

MM | DD | YYYY

Does this claim relate to a Motor Vehicle Accident?  No  Yes

Name of Motor Vehicle Insurance Company Policy # Phone

( )

Address City Province Postal Code

ACM is committed to protecting the privacy, confidentiality and security of the personal information we collect, use and disclose. Your personal information will be used only for the purpose of providing you with the requested insurance services. For a copy of ACM’s privacy policy, please contact us.

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EMERGENCY TRAVEL MEDICAL CLAIM FORM

Active Care Management | P.O. Box 1237 Station A Windsor Ontario N9A 6P8

SECTION C – MEDICAL INFORMATION – Please list the name and telephone number of your Family Physician as well as any Specialists that you have been or are currently seen by.

Name of Usual Canadian Physician (Family Doctor) Phone

( )

Physician’s Name & Specialty Phone

( )

Physician’s Name & Specialty Phone

( ) Was this condition related to a Pregnancy?  No  Yes, If Yes, Expected Date of Delivery MM | DD | YYYY Injury

Is this claim the result of an Injury?  No  Yes Date of Injury

MM | DD | YYYY Brief Description of Injury and Diagnosis

Sickness

Date Symptoms first appeared MM | DD | YYYY

First date of Treatment MM | DD | YYYY

Diagnosis

Treating Doctor’s Name Phone

( ) List names of any Medications you were taking prior to visiting the Doctor:

Have you ever experienced this sickness or a similar problem before?  No  Yes Date of Previous Occurrence MM | DD | YYYY

Do you have any Chronic Sickness or Disease?  No  Yes Date Diagnosed

MM | DD | YYYY Describe Conditions / Diagnosis:

SECTION D – CERTIFICATION & AUTHORIZATION – Signature required below.

The insurer, its agents and administrators are obliged to collect and retain certain personal and/or health information about you in connection with your insurance coverage. They use and disclose that information only for the purposes of administering your policy/policies of insurance, providing customer service and assessing and paying claims.

I/We authorize any licensed physician, medical practitioner, hospital, clinic, other medical facility or provider of health care, insurer or reinsurer, provincial health insurance plan and employer(s) to provide Active Care Management (ACM), and its representatives employed to assist in the administration of this claim, any information, including personal information, data or records t hat are in their possession/knowledge regarding my medical history and treatment.

I/We direct and authorize my Government Health Insurance Plan (GHIP) to make payment in respect of my claim for out of country Health services to ACM, directly and I hereby release GHIP, upon payment to ACM from any further claim or cause of action in connection herewith.

I hereby consent and authorize GHIP to directly or indirectly collect information contained in the claim and source documents pursuant to the freedom of information and protection of privacy act, and the Health Insurance Act.

I/We authorize ACM to coordinate the payment of benefits with any other insurance carriers which may also have a liability for this claim. I/We hereby irrevocably direct ACM to make any payments, receive payments and settle with other carriers on my/our behalf.

I hereby consent to the use of ACM, the insurers its agents and administrators of the personal and health information about me disclosed herein and in all documents or information provided in connection with my policy/policies of insurance for purposes cited above.

A photocopy of this authorization shall be considered as effective and valid as the original. This authorization shall be considered valid for the duration of the claim, but not to exceed one year from date signed.

I certify that the information provided in connection with this claim is complete, true and accurate.

Notice: The provincial legislation in some provinces requires us to inform you that the time limit for taking legal action is set out in the Insurance Act or other legislation that applies to your claim.

Policyholder’s Signature (If minor, signature of parent or legal guardian) Date

MM | DD | YYYY Name of Patient/Insured (Last Name, First Name, Middle Initial) Date

MM | DD | YYYY If you authorize payment of this claim to anyone other than yourself or your provider, please

provide name of recipient:

Date

MM | DD | YYYY

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Expense Sheet

Name of Insured:_____________________________________

Please list below any PAID out of pocket expenses. Please note, your claim will not be processed unless original documentation is supplied. If you receive additional bills after submission of this expense sheet, contact our office for additional instructions prior to making a payment.

Facility Name (pharmacy, doctor, etc.)

Description of Expense (prescription)

Date of Service (mm/dd/yy)

Amount Paid by Insured

Type of Currency

Date Paid (mm/dd/yy)

Receipt attached (if no, please explain in comment section below)

Yes No

Comments (please use back of page if required)

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RESIDENTS OF: BRITISH COLUMBIA THIS SECTION MUST BE COMPLETED PRIOR TO ANY MEDICAL CLAIM PAYMENTS

AUTHORIZATION TO PROVIDE MEDICAL INFORMATION AND ASSIGNMENT OF PAYMENT TO INSURED PERSON OR BENEFICIARY UNDER THE MEDICARE PROTECTION ACT OR HOSPITAL INSURANCE ACT

GOVERNMENT HEALTH PLAN SECTION

AUTHORIZATION & RELEASE

DATED this

BETWEEN of the first part hereinafter referred to as the Assignor

day of

, 20 SIGNATURE OF

ASSIGNOR ASSIGNMENT:

: O T M

O R F E V I T C E F F

E ^PERSONALHEALTHCARD NO.

WITNESS

SIGNATURE ^OCCUPATION

ADDRESS

CITY PROVINCE ^POSTAL_CODE

TELEPHONE _{( )}

of the second part hereinafter referred to as the Assignee PO BOX 4906 STN A, TORONTO, ONTARIO M5W 0B4

r e t s i n i M e h t s a o t d e r r e f e r r e t f a n i e r e h F

O E C N I V O R P E H T F O T H G I R E H T N I N E E U Q E H T Y T S E J A M R E H D N A

D N A

BRITISH COLUMBIA AS REPRESENTED BY THE MINISTER OF HEALTH

WHEREAS the Assignor is a person eligible for insured services or benefits or both under the Province of British Columbia’s Medicare Protection Act or Hospital Insurance Act or both, and as such may receive payment for the above services from the Minister.

And WHEREAS the Assignor is under a covenant or obligation under a contract with the Assignee to remit to the Assignee all such payments received for medical services from the Minister.

NOW WITNESSETH THAT in consideration of the said obligation to the Assignee the Assignor hereby assigns unto the Assignee all sums of money that shall be owing to the Assignor by the Minister for the above noted contract. The Minister is hereby authorized to pay all such sums directly to the Assignee at the address aforesaid, or at any address the Assignee may from time to time designate, with payment of any such sum to be sufficient discharge to the Minister of and from any indebtedness in that amount to the Assignor, his heirs, executors, or administrators.

RESIDENTS OF: SASKATCHEWAN THIS SECTION MUST BE COMPLETED PRIOR TO ANY MEDICAL CLAIM PAYMENTS

AUTHORIZATION TO PROVIDE MEDICAL INFORMATION AND ASSIGNMENT OF PAYMENT TO INSURED PERSON OR BENEFICIARY UNDER THE MEDICARE PROTECTION ACT OR HOSPITAL INSURANCE ACT

GOVERNMENT HEALTH PLAN SECTION

AUTHORIZATION & RELEASE

DATED this

BETWEEN of the first part hereinafter referred to as the Assignor

day of

, 20 SIGNATURE OF

ASSIGNOR ASSIGNMENT:

: O T

EFFECTIVE FROM ^PERSONALHEALTHCARD NO.

WITNESS

SIGNATURE ^OCCUPATION

ADDRESS

CITY PROVINCE ^POSTAL_CODE

TELEPHONE _{( )}

PO BOX 4906 STN A, TORONTO, ONTARIO M5W 0B4

r e t si n i M e h t s a o t d e r r e f e r r e t f a n i e r e h F

O E C N I V O R P E H T F O T H G I R E H T N I N E E U Q E H T Y T S E J A M R E H D N A

D N A

SASKATCHEWAN AS REPRESENTED BY THE MINISTER OF HEALTH

WHEREAS the Assignor is a person eligible for insured services or benefits or both under The Saskatchewan Medical Care Insuranc e Act or The Saskatchewan Hospitalization Act or both, and as such may receive payment for the above services from the Minister.

And WHEREAS the Assignor is under a covenant or obligation under a contract with the Assignee to remit to the Assignee all such payments received for medical services from the Minister.

NOW WITNESSETH THAT in consideration of the said obligation to the Assignee the Assignor hereby assigns unto the Assignee all sums of money that shall be owing to the Assignor by the Minister for the above noted contract. The Minister is hereby authorized to pay all such sums directly to the Assignee at the address aforesaid, or at any address the Assignee may from time to time designate, with payment of any such sum to be sufficient discharge to the Minister of and from any indebtedness in that amount to the Assignor, his heirs, executors, or administrators.

Y M

D Y

M D

Y M

D Y

M D

of the second part hereinafter referred to as the Assignee

RESIDENTS OF: BRITISH COLUMBIA THIS SECTION MUST BE COMPLETED PRIOR TO ANY MEDICAL CLAIM PAYMENTS

GOVERNMENT HEALTH PLAN SECTION

AUTHORIZATION & RELEASE

GOVERNMENT HEALTH PLAN SECTION

AUTHORIZATION & RELEASE

RESIDENTS OF: SASKATCHEWAN THIS SECTION MUST BE COMPLETED PRIOR TO ANY MEDICAL CLAIM PAYMENTS

THE MANUFACTURERS LIFE INSURANCE COMPANY C/O MANULIFE FINANCIAL.

THE MANUFACTURERS LIFE INSURANCE COMPANY C/O MANULIFE FINANCIAL

D M Y D M Y

I HEREBY CONSENT TO AND AUTHORIZE THE MINISTRY OF HEALTH TO FURNISH ANY REPRESENTATIVE OF THEMANUFACTURERS LIFEINSURANCECOMPANY (MANULIFE F !"!# "$%&"!'&"!(&"$$&)*#+)(,&"!(& !-+)."/ +!& !&/0*&. ! ,/)'&+-&0*"$/01,&2+,,*,, +!&)*3")( !3&#$" .,&-+)&.*( #"$&,*)4 #*,& !#5))*(&60 $*& HAD INSURANCE COVERAGE FOR THE ASSIGNMENT PERIOD INCLUDING MEDICAL HISTORY AND PHYSICAL CONDITION BOTH PRIOR AND SUBSEQUENT TO RECEIPT OF .*( #"$&,*)4 #*,7&)*3")($*,,&+-&$"2,*(&/ .*&"!(&8*") !3& !&"!'&6"'&+!&/0*&,*)4 #*,&)*#* 4*(&(5) !3&/0*&"8+4*&/ .*&2*) +(9

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