DEMANDE DE RÈGLEMENT – ASSURANCE VOYAGE

Form Language
Important notice
A completed and signed claim is essential even if you have not paid anything. Your public health insurance plan covers part of the cost of medical care you received while travelling. CanAssistance fully reimburses these costs, but must submit them to your provincial insurance plan.

In accordance with the terms and conditions of the contract, by signing the form, you authorize CanAssistance to:
- Access your personal information and medical information relevant to the evaluation of your claim;
- Pay service providers directly when expenses are eligible.
Failure to complete this claim form entitles CanAssistance to ask you to refund the fees that were paid on your behalf.

You must have the following scanned documents on hand before proceeding with your claim:
- Original and detailed invoices for all health services received, diagnosis and treatment must be clearly indicated.
- Original prescription drug receipts showing drug name, dosage and price.
- Proof of payment for all expenses claimed, such as a copy of a credit card statement. In the absence of a statement, a transaction receipt may be accepted. If proof of payment was made in cash, the Bank of Canada rate will be used for reimbursement.
- Proof of your departure and return dates, such as a plane ticket, train ticket, copy of stamped passport, bank or credit card statement showing purchases in Canada just before your departure and immediately after your return.
- Any other relevant documents (if applicable), such as medical reports, laboratory results, etc.
- Written attestation from the educational institution, specifying the start and end dates of your courses (if applicable).
- Sample cheque if you wish to be compensated by direct deposit.
- If several insured persons have received medical treatment, each person must complete a form.
- The claim form must be signed by the beneficiary (the person who received health services). If the request concerns a minor insured, it must be signed by the policyholder.
Please select your home province :

Reimbursement

Fees claimed (please enter the claimed amount using the following format 99.99).

Rows	Description of expenses (e.g., medical consultation, medication)	Name of provider / facility	Amount paid (enter 0 if no amount paid)	Currency	Claimed amount (CAD)
1
2
3
4
5
6
7
8
9
10

Frais réclamés (merci d’inscrire les montants réclamés selon le format suivant 99,99).

Rows	Description des frais (Ex. : consultation médicale, médicament)	Nom du fournisseur / établissement	Montant payé (si vous n’avez rien déboursé, indiquez 0)	Devise	Montant réclamé (CAD)
1
2
3
4
5
6
7
8
9
10

Total claimed amount (CAD)

Request for payment by direct deposit
Important notice

If your claim is eligible, a payment will be issued to the policyholder, by default as a cheque.
Payment should be made to
Third party: CanAssistance Inc.
Address of third party
1981 McGill College Avenue, Suite 400,
Montreal, Quebec, H3A 2W9
Canada
Would you prefer to receive your payment by direct deposit instead of by cheque? If yes, please enter the details of the account belonging to the policyholder to which your benefits will be paid by electronic funds transfer (direct deposit)
{nomSignataire}

______________________________

Electronic signature
Date

JourMoisAnnée
We recommend that you select direct deposit for a number of reasons:
- Avoid the many possible days that come with receiving cheques by mail.
- Access your funds immediately without any holds that may be required by your financial institution.
Bank Account Details (Canadian financial institutions only)
Kindly make sure the banking information you enter below is accurate, as any discrepancies will prevent the direct deposit from being processed.
Policyholder name*
Branch number (5 digits)*
Institution number (3 digits)*
Account number (7 to 12 digits)*
Policyholdre Name-Direct Deposit
Branch number 5dig-Direct Deposit
Institution number 3dig-Direct Deposit
Account number 7-12dig-Direct Deposit
Please attach a sample cheque. It is possible to obtain an electronic version using your financial institution's online banking services. You may also send us a photo of a voided cheque, ensuring that all information is legible.
Sample cheque

Cancelof
Any additional information
Your claim will be reviewed as quickly as possible once we’ve received the required documents. The following situations may increase the time it takes us to process your claim:
- An incomplete claim form or missing document
- Delayed or missing detailed invoice
- Delayed or missing medical information
Eligible expenses are reimbursed in Canadian currency to the policyholder.. If you’re covered by more than one travel insurance policy, indicate this on your claim form. We will work with your other insurer to coordinate your benefits as needed.

If you receive a bill, please do not make any payments directly to the service provider unless we instruct you to do so. Simply send it to the address above.

Should you have any questions about your claim, please contact us by using the phone number on your insurance card or visit our website at: canassistance.com

Mandate – Ontario resident
1. I, the undersigned First and last name (or, I First and last name parent/guardian of minor First and last name, a minor) authorize CanAssistance Inc. and its signing officers as my attorneys to receive in my name and endorse and negotiate on my behalf, cheques and other forms of payment from my provincial or territorial health insurance plan (OHIP) for the reimbursement of claims relating to hospital and medical services incurred during a trip outside my place of residence during my coverage period, including any authorized extension of such coverage, and in accordance with my travel insurance plan.
2. I irrevocably direct and authorize OHIP to make payment in respect of my claim for health services incurred during such trip to CanAssistance Inc. directly and I hereby release OHIP, upon payment to CanAssistance Inc. from any further claim or cause of action in connection therewith.
3. I hereby consent and authorize Canassistance Inc. and OHIP to directly or indirectly collect information contained in the claim and source documents pursuant to applicable provincial legislation.
4. I consent to the disclosure by OHIP to CanAssistance Inc. of such personal information as may be necessarily required for the processing of my claim for such health services, including the details of any duplicate payment previously made directly to me.
5. I hereby agree to assign to CanAssistance Inc. all benefits payable by third parties for losses covered under the policy. Furthermore, following the application for reimbursement from CanAssistance Inc., I authorize third parties to pay CanAssistance Inc., the benefits payable regarding these losses.
6. I authorize CanAssistance Inc. to provide the information contained in my claim file to third parties, for their use, within the context of this claim, to determine the benefits payable, if the case arises.
7. I certify that the information contained herein is true and complete to the best of my knowledge and I hereby authorize any licensed physician, practitioner, hospital or medical institution, insurance company, OHIP, the Medical Information Bureau or any other agency, institution or person who has information or documents about me or a member of my family, or my state of health or that of a member of my family (including all previous medical reports) to convey that information or forward those documents to CanAssistance Inc.
Mandate – Manitoba resident
1. I, the undersigned First and last name* (or, I First and last name-TEST* parent/guardian of minor First and last name*, a minor) hereby:
  1. consent to and authorize Manitoba Health to furnish to any representative of Canassurance Hospital Service Association and CanAssistance Inc. claim and payment information in Manitoba Health's possession in respect of claims for Medical Services incurred during my coverage period (in accordance with my travel insurance policy) including physician/hospital name, date of service, and services provided (in-patient, out-patient, physiotherapy, visit, procedure, X-ray or laboratory services).
  2. direct Manitoba Health to forward payment to Canassurance Hospital Service Association and CanAssistance Inc. for any claims for benefits under the Health Services Insurance Act submitted by Canassurance Hospital Service Association and CanAssistance Inc. in respect of medical and hospital services provided outside Manitoba.
2. I hereby consent and authorize Canassurance Hospital Service Association and CanAssistance Inc. to directly or indirectly collect information contained in the claim and source documents pursuant to applicable provincial legislation.
3. I hereby agree to assign to Canassurance Hospital Service Association and CanAssistance Inc. all benefits payable by third parties for losses covered under the policy. Furthermore, following the application for reimbursement from Canassurance Hospital Service Association and CanAssistance Inc., I authorize third parties to pay Canassurance Hospital Service Association and CanAssistance Inc., the benefits payable regarding these losses.
4. I authorize Canassurance Hospital Service Association and CanAssistance Inc. to provide the information contained in my claim file to third parties, for their use, within the context of this claim, to determine the benefits payable, if the case arises.
5. I certify that the information contained herein is true and complete to the best of my knowledge and I hereby authorize any licensed physician, practitioner, hospital or medical institution, insurance company, the Medical Information Bureau or any other agency, institution or person who has information or documents about me or a member of my family, or my state of health or that of a member of my family (including all previous medical reports) to convey that information or forward those documents to Canassurance Hospital Service Association and CanAssistance Inc.
1. I, the undersigned First and last name* (or, I First and last name* parent/guardian of minor First and last name*, a minor) hereby:
  1. consent to and authorize Manitoba Health to furnish to any representative of Canassurance Insurance Company and CanAssistance Inc. claim and payment information in Manitoba Health's possession in respect of claims for Medical Services incurred during my coverage period (in accordance with my travel insurance policy) including physician/hospital name, date of service, and services provided (in-patient, out-patient, physiotherapy, visit, procedure, X-ray or laboratory services).
  2. direct Manitoba Health to forward payment to Canassurance Insurance Company and CanAssistance Inc. for any claims for benefits under the Health Services Insurance Act submitted by Canassurance Insurance Company and CanAssistance Inc. in respect of medical and hospital services provided outside Manitoba.
2. I hereby consent and authorize Canassurance Insurance Company and CanAssistance Inc. to directly or indirectly collect information contained in the claim and source documents pursuant to applicable provincial legislation.
3. I hereby agree to assign to Canassurance Insurance Company and CanAssistance Inc. all benefits payable by third parties for losses covered under the policy. Furthermore, following the application for reimbursement from Canassurance Insurance Company and CanAssistance Inc., I authorize third parties to pay Canassurance Insurance Company and CanAssistance Inc., the benefits payable regarding these losses.
4. I authorize Canassurance Insurance Company and CanAssistance Inc. to provide the information contained in my claim file to third parties, for their use, within the context of this claim, to determine the benefits payable, if the case arises.
5. I certify that the information contained herein is true and complete to the best of my knowledge and I hereby authorize any licensed physician, practitioner, hospital or medical institution, insurance company, the Medical Information Bureau or any other agency, institution or person who has information or documents about me or a member of my family, or my state of health or that of a member of my family (including all previous medical reports) to convey that information or forward those documents to Canassurance Insurance Company and CanAssistance Inc.
Consent and authorization
1. I, the undersigned Full name of beneficiary/patient* (or, I Full name of parent/guardian* parent/guardian of Full name of beneficiary/patient) authorize CanAssistance inc. and its signing officers as my attorneys to receive in my name and endorse and negotiate on my behalf, cheques and other forms of payment from my provincial or territorial health insurance plan for the reimbursement of claims relating to hospital and medical services incurred during a trip outside my place of residence uring my coverage period, including any authorized extension of such coverage, and in accordance with my travel insurance plan.
2. I irrevocably direct and authorize my provincial or territorial health insurance plan to make payment in respect of my claim for health services incurred during such trip to canassistance inc. directly and i hereby release my provincial or territorial health insurance plan, upon payment to CanAssistance inc. from any further claim or cause of action in connection therewith.
3. I hereby consent and authorize CanAssistance inc. and my provincial or territorial health insurance plan to directly or indirectly collect information contained in the claim and source documents pursuant to applicable provincial legislation.
4. I consent to the disclosure by my provincial or territorial health insurance plan to canassistance inc. of such personal information as may be necessarily required for the processing of my claim for such health services, including the details of any duplicate payment previously made directly to me.
5. I hereby agree to assign to CanAssistance inc. all benefits payable by third parties for losses covered under the policy. furthermore, following the application for reimbursement from CanAssistance inc., i authorize third parties to pay CanAssistance inc., the benefits payable regarding these losses.
6. I authorize CanAssistance inc. to provide the information contained in my claim file to third parties, for their use, within the context of this claim, to determine the benefits payable, if the case arises.
7. I certify that the information contained herein is true and complete to the best of my knowledge and i hereby authorize any licensed physician, practitioner, hospital or medical institution, insurance company, my provincial or territorial health insurance plan, the medical information bureau or any other agency, institution or person who has information or documents about me or a member of my family, or my state of health or that of a member of my family (including all previous medical reports) to convey that information or forward those documents to CanAssistance inc.

Nom signataire (Hidden)
Nom parent (Hidden)
Nom mineur (Hidden)
Nom signataire manitoba(Hidden)
N/A (Hidden)
Beneficiary is a Minor?
Beneficiary/Patient has Parent/Guardian?
Beneficiary/Patient without Parent/Guardian
Beneficiary/Patient with Parent/Guardian
Parent/Guardian
I agree with the previous 7 points.
I agree with the previous 5 points.
{nomSignataire}

______________________________

Electronic signature
Date

JourMoisAnnée
If not the beneficiary, relationship to beneficiary :
parent, legal guardian, etc.

Newfoundland and Labrador
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.
I, certify that the information provided above on this form is true and correct.
{nomSignataire}

______________________________

Electronic signature
Date

JourMoisAnnée
Insurance Claim Consent and Authorization Alberta
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.
I, certify that the information provided above on this form is true and correct.
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.
Date

JourMoisAnnée
SCHEDULE A - ASSIGNMENT OF PAYMENT - BRITISH COLUMBIA
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

HIS MAJESTY THE KING 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}
I, certify that the information provided above on this form is true and correct.
{nomSignataire}

______________________________

Signature of Assignor (Patient or Parent/Guardian of Patient)
Date

JourMoisAnnée
SCHEDULE B - AUTHORIZATION TO PROVIDE MEDICAL INFORMATION - BRITISH COLUMBIA
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, certify that the information provided above on this form is true and correct.
{nomSignataire}

______________________________

Signature of Assignor (Patient or Parent/Guardian of Patient)
Date

JourMoisAnnée
Release of information British Columbia
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.
I certify that I am the person entitled to receive benefits and that all statements made by me are true and correct.
{nomSignataire}

______________________________

Electronic signature
Date

JourMoisAnnée
Please confirm that you are a human being

Should be Empty:

Important notice

Beneficiary (patient)

Policyholder / Primary credit cardholder

Additional information - British Columbia

SECTION A – PATIENT INFORMATION

Attach all applicable documents

Other insurance – coordination of benefits

Incident information

Stay outside home province

Healthcare services outside home province

Healthcare services in your home province

Reimbursement

Request for payment by direct deposit

Important notice

Bank Account Details (Canadian financial institutions only)

Any additional information

Mandate – Ontario resident

Mandate – Manitoba resident

Consent and authorization

Newfoundland and Labrador

Insurance Claim Consent and Authorization Alberta

SCHEDULE A - ASSIGNMENT OF PAYMENT - BRITISH COLUMBIA

SCHEDULE B - AUTHORIZATION TO PROVIDE MEDICAL INFORMATION - BRITISH COLUMBIA

Release of information British Columbia