CLAIM FORM FOR OUT OF CANADA H.S.M.

EXPENSE BENEFIT
Green Shield Travel Assistance THE DETAILS REQUESTED BELOW ARE MANDATORY FOR
Allianz Global Assistance THE PROCESSING OF YOUR CLAIM(S). Please complete this form
4273 King Street East
Kitchener, ON N2P 2E9 in full and submit it to Green Shield along with an original itemized
statement (outlining a breakdown of charges and the patient’s diagnosis).

SECTION 1 - MUST BE COMPLETED BY THE PROVIDER OF SERVICE

PROVIDER INFORMATION PATIENT INFORMATION
Provider Number Provider Telephone Number Green Shield Identification Number

Provider Name Patient's Name Date of Birth

Address Address

City Province/State Postal Code/Zip Code City Province/State Postal Code/Zip Code

Date of Treatment Type of

DESCRIPTION OF TREATMENT RENDERED Year Month Day Charge Currency

Was Green Shield contacted to obtain preauthorization I certify that the treatment described above was rendered by me.
for this service? Yes No
_______________________________________________________
If Yes, please provide the date preauthorization was issued. Signature of Provider or Authorized Hospital Official
________________________

SECTION II - MUST BE COMPLETED BY THE PATIENT/GUARDIAN

This plan supplements any government provided hospital, surgical or medical benefits that you may be eligible for based on the laws of the country
in which you reside. All applicable government exemptions or subsidies based on age, residency, disability, income, etc. must be applied for before a
claim can be submitted under this plan.

Do you have any other insurance coverage that may include this claim as a benefit. Yes * No
* If Yes, either a copy of the payment statement or a denial letter from the primary carrier must be attached.

I certify that the above treatment was rendered Please provide payment to the provider named above.
Please reimburse me, as I have paid the provider.

_____________________________________________________ ______________________________________________________
Signature of Patient/Guardian Signature of Patient/Guardian
By signing this claim form and/or submitting actual receipts, I agree that the information provided on this form is complete and accurate. I understand that
the information provided by me to Green Shield Canada about myself and my dependents, will be used by Green Shield Canada for claims adjudication and
any other services necessary in the administration of our benefits which may include the exchange of information with other parties to administer this benefit
claim.
I am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this
information may be seen by the cardholder.

Claim Form for Out of Canada H.S.M. Expense Benefit EN (Rev. 2013-04)