Online Claim Form | The Benefits Trust

Complete the sections below, attach electronic copies of your receipts and click submit for your claim to be processed.

Personal Details

Member Name:

Member Email Address:

Member Certificate Number:

Group/Policy Number:

Drug Claims:

List all prescriptions purchased. Please attach receipts for every expense. Attach your physician's written recommendation and diagnosis where applicable.

Note: All fields are required except for Dispensing Fee

Note: Touch title area to scroll.

Name of Patient

Birth Date

Relation to Member

Date of Expense

DIN

Dispensing Amount Fee

Amount Charged (Drug Cost)

Total Charged

Add Another Purchase

Total

Attach Receipt Images
Maximum 4Mb File Size per Attachment

Remove Add More Files

Medical and Vision Claims:

List all services and/or items purchased. Please attach receipts for every expense. Attach your physician's written recommendation and diagnosis where applicable.

Note: All fields are required

Note: Touch title area to scroll.

Name of Patient

Birth Date

Relation to Member

Date of Expense

Type of Expense

Subtype

Total Charged

Add Another Purchase

Total

Attach Receipt Images
Maximum 4Mb File Size per Attachment

Remove Add More Files

Dental Claim:

Complete all sections in the form below for each dental procedure. Attach a copy of the dental claim statement provided by your dental office.

Note: All fields are required except for Lab Charge, Tooth Surface and Tooth Code (provide these if available)

Note: Touch title area to scroll.

Name of Patient

Birth Date

Relation to Member

Date of Service

Procedure Code
(5 digit)

Tooth Code

Tooth Surface

Lab Charge
(If applicable)

Dentist's Fee

Total Charged

Add Another Procedure

Total

Attach Receipt Images
Maximum 4Mb File Size per Attachment

Remove Add More Files

Coordination of Benefits

Is this medical care covered by any other group insurance? Yes No

If yes, Name of Insured:

Name of Insurance Company:

Policy Number:

Health Care Spending Account (Expenses must be eligible under the Income Tax Act)

Do you want any part of this claim to be paid through your Health Care Spending Account? Yes No

If Yes

Please attach receipts, or if expenses have been submitted under this or another plan and you are now claiming for the unpaid portion, please attach receipts plus the Explanation of Benefits from the previous submission
Please indicate whether you want:

All of the remaining portion of the claim to be paid

A specific amount $

Attach Receipt Images
Maximum 4Mb File Size per Attachment

Remove Add More Files

Notes

I hereby certify that the above information is true to the best of my knowledge and that these expenses were incurred by myself (or my dependants) for the exclusive use of the person for whom the expense was incurred, as indicated above. I authorize The Benefits Trust and its administrators to use my social insurance number for identification purposes in the handling of my claim. In addition, I also authorize my Employer and The Benefits Trust (including its affiliates and/or insurance partners) to exchange the information detailed in this Claim Form and any other benefit related information contained in files regarding me or my dependents, now or in the future, for the purposes of administration and/or management of the Benefit Services Contract issued by The Benefits Trust. An electronic, photostatic or facsimile copy of this authorization shall be as valid as the original.

Personal Details

Drug Claims:

Attach Receipt Images Maximum 4Mb File Size per Attachment

Medical and Vision Claims:

Attach Receipt Images Maximum 4Mb File Size per Attachment

Dental Claim:

Attach Receipt Images Maximum 4Mb File Size per Attachment

Coordination of Benefits

Health Care Spending Account (Expenses must be eligible under the Income Tax Act)

Attach Receipt Images Maximum 4Mb File Size per Attachment

Notes

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Attach Receipt Images
Maximum 4Mb File Size per Attachment

Attach Receipt Images
Maximum 4Mb File Size per Attachment

Attach Receipt Images
Maximum 4Mb File Size per Attachment

Attach Receipt Images
Maximum 4Mb File Size per Attachment