If no, provide below the residential address(es) where patient was living

I hereby declare, conscientiously believing it to be true and knowing it to have the same effect as if it were made under oath and by virtue of the Canada Evidence Act, that the information given above is correct and that I am a beneficiary of the Newfoundland & Labrador Medical Care Plan.

The information on this form is being collected and used by Alberta Health pursuant to sections 20(a) and (b) of the Health Information Act and section 33(c) of the Freedom of Information and Protection of Privacy Act for the purpose of assigning the payment of insured medical under the Alberta Health Care Insurance Plan and insured hospital services under the Hospitalization Benefits Plan to the insurer of third party named in this form. If you have questions about the collection and use of this information, please contact an Alberta Health representative toll free within Alberta at 310-000 then 780-427-1432.

Note: Failure to complete all sections of this form will result in Alberta Health not releasing health information or reimbursing an
insurance claim. Proof of payment must be submitted with the insurance claim.

Patient Information

{nomCompletBeneficiaire} Alberta Personal Health Number (PHN) {healthNumber32}

 

Authorization for Release of Health Information

My health information can be released to:

CanAssistance Inc.

Name of insurance company, and where applicable, the name of a broker submitting on behalf of the insurance company, or third party who is not an insurer (e.g. junior hockey clubs, churches).
to permit Alberta Health for reimbursement of health benefits paid on my behalf for the cost of insured health services by the insurer or third party which I received outside of Alberta.

 

Authorization of Payment
I, {nomSignataire}  hereby assign to CanAssistance Inc. any amounts payable to me by Alberta Health for out of country health benefits.

Effective Date
This consent is effective From {dateOf} To {dateRetourET18mois} (at least 18 months from the earliest date of service to ensure sufficient time for processing). Please note: the submitter has up to 365 days from the date of medical service to submit a claim to Alberta Health.

Declaration
I, the patient, authorize disclosure of the following information for the purposes of Alberta Health to reimbursing health benefits paid on my behalf for the cost of insured health services received outside of Alberta, which may include the following: date(s) of service(s), type(s) of service(s) and reason(s) for service(s), amount(s) paid, name(s) of service provider(s), and where applicable, the facility name, and personal health number.
I also understand I have been asked to authorize disclosure of this information so as to permit Alberta Health to reimburse the identified insurance company, or third party who is not an insurer that has paid a medical service claim on my behalf, and I am aware of the risks and benefits of consenting, or refusing to consent to the disclosure. I further understand that this consent may be revoked by submitting such revocation to the Out-of-Country Claims Unit of Alberta Health.

Personal Health Number (PHN) of Patient : {healthNumber32}

 

BETWEEN

Assignor (Adult Patient, or Parent/Guardian of Patient) : {nomSignataire}   

AND

Assignee (Insurance Company) : CanAssistance Inc.  ;    MSP Account Number: 900 32

AND

HER MAJESTY THE QUEEN IN THE RIGHT OF THE PROVINCE OF BRITISH COLUMBIA AS REPRESENTED BY THE MINISTER OF HEALTH SERVICES, hereinafter referred to as the Minister.

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

And WHEREAS the Assignor is bound by an obligation under a contract or agreement with the Assignee to remit to the Assignee all payments received for such insured services and/or benefits from the Minister.

THEREFORE, in consideration of the obligation to the Assignee, the Assignor hereby assigns to the Assignee all sums of money that shall be owing to the Assignor by the Minister in relation to the insured services and/or benefits referred to above. The Minister is hereby authorized to pay all such sums directly to the Assignee at the address noted above, or at any address the Assignee may from time to time designate, with payment of any such sum to be a complete discharge of the Minister from any indebtedness in the amount to the Assignor, his heirs, executors, or administrators.

By signing this form, you will be assigning your MSP and hospital insurance benefit to the insurance company (Assignee) named above.

Payment assignment is effective from: {dateOf} To {Id_demRegl_Pag2_Mandat_Quest_dateDebut}

Personal Health Number (PHN) of Patient : {healthNumber32}

 

Name of Adult Patient, or Parent/Guardian of Patient : {nomSignataire}

Name of Minor-aged Patient (if applicable) : {mandat342:5}

Address : {1Home}, {country}

Telephone Number : {primaryPhone}

Insurance Company : CanAssistance

Insurance Coverage : FROM   {dateOf}   TO   {Id_demRegl_Pag2_Mandat_Quest_dateDebut}

 

I, the above-named adult, hereby consent to and authorize the Ministry of Health (“the Ministry”) to provide to an authorized representative of the above-named insurance company(“the Insurer”), for the use by the Insurer in assessing entitlement to benefits, any and all records and information in the possession of the Ministry regarding claims for medical or health care services incurred while
I had insurance coverage with the Insurer during the period noted above, including records and information relating to medical history and physical condition both prior and subsequent to receipt of the medical or health care services.

I, the patient named above, hereby authorize Medical Services Plan to obtain information necessary for the processing of my claim from the Hospital and/or Doctor who provided care or in the event of an appeal on this case to provide the appeal board with the appropriate information in order for an informed decision to be made.
I also authorize Medical Services Plan to provide/obtain information to/from the above named travel insurance or extended health benefits company.

CanAssistance Inc.

In addition, my signature below is my Application for Benefits under the Hospital Insurance Act of British Columbia.