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Additional supplies of this form are available at www.greenshield.ca. Canada about myself and my dependents, will be used by Green Shield Canada for
Do you want to coordinate this claim with your other Green Shield Canada Coverage? I certify that the information in this form and any further verbal or written
Green Shield Dental Claim Form Green Shield General Claim Submission Form Green Shield Coverage for Over-Age Dependants(s) in Full-Time Studies
Results 21 - 30 What information is required on a health and dental claim form? All claim . up for direct deposit; Download personalized claim forms; Check .
If other coverage is with Green Shield Canada, indicate other Green Shield By signing this claim form and/or submitting actual receipts, I agree that the
I UNDERSTAND THAT THE CHARGES LISTED IN. THIS CLAIM MAY NOT BE COVERED BY OR MAY. EXCEED MY AGREEMENT BENEFITS. I.
General Claim Submission Form EN (2012-01). GENERAL CLAIM If other coverage is Green Shield Canada, indicate Green Shield Canada ID number:
There is no need to attach receipts if this form is completed in full by the provider. If other coverage is Green Shield, indicate Green Shield ID number:
I understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. I understand that I am financially responsible to my provider
PROVIDER-SUBMITTED CLAIMS. Have to submit a paper claim? If you are covered for health or dental benefits under another benefits plan, you can coordinate with your GSC benefits to receive up to 100% coverage by accessing both plans.
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