City, Province, Postal Code
Date of Birth
Primary Coverage Insurer / Payer
Primary Member Coverage Name
Date of Birth
Primary coverage policy number (also referred to as group or contract number)
Primary coverage certificate (also referred to as member/identification number)
(Canada Life only) secondary coverage plan member name
Consent to Collect and Exchange Personal Information
Personal information that we collect and disclose about you, and if applicable, is used by the insurer, and/or plan administrator of
your group benefits plan, its affiliates and their service provider(s) for the purposes of assessing eligibility for your claims, underwriting,
investigating, auditing and otherwise administering the group benefits plan, including the investigation of fraud and / or plan abuse
and for internal data management and data analytical purposes.
Authorization and consent
I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf
with the insurer and/or plan administrator and their service provider(s) for the above purposes.
I authorize such insurer and / or plan administrator and their service provider(s) to:
• use my personal information for the above purposes.:
• exchange personal information with any individual or organization, including healthcare professionals, investigative agencies,
insurers and reinsurers, and administrators of government benefits, or other benefits programs, other organizations, or service
providers working with such insurer and/or plan administrator or any of the foregoing, when relevant for the above purposes.:
• where applicable exchange personal information concerning any claims with any assignee of benefits payable and exchange
personal information for the above purposes electronically or in any other manner.
I understand that personal information may be subject to disclosure to those authorized under applicable law.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the
continued administration of the group benefits plan.
In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning any claims submitted, I acknowledge and agree
that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant
organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and
where applicable my employer or benefit plan sponsor, for the purposes of investigation and prevention of fraud and/or benefit plan
abuse. I understand that the submission of fraudulent claims is a criminal offence.
If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group
benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where
applicable, my benefit plan sponsor, for that purpose.
If the patient is a person other than myself, I confirm that the patient has given their consent to provide their personal information for the
healthcare provider and the insurer and/or plan administrator and their service provider(s) to use and disclose their personal information
as set out above.
Benefit Assignment Form
I hereby assign benefits payable for the eligible claims to the healthcare provider responsible for submitting my claims electronically to
the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to such provider. In the event my claim(s)
are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the healthcare provider for any services
rendered and/ or supplies provided.
I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this benefit assignment form, that any
benefit payment made in accordance with this benefit assignment form will discharge the insurer/plan administrator of its obligations
with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be
discharged of its obligation with respect to that benefit payment.
I understand that this assignment will apply to all eligible claims submitted electronically by my healthcare provider and that I may revoke
it at any time by providing written notice to the insurer/plan administrator.
If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the
Typing my complete name on the signature line below and dating this document will have the same legal effect as afixing my true signature to this document. I understand that I may not submit this document without a signature and date.
Pressing This Button will submit the form to All About U Massage