Claim Submission Form
Use this form to submit a health or dental claim online
I/We declare the statements made herein are true and complete. For the purposes of administering any Group Medical Services
("GMS") benefits, products or services (collectively "benefits") and/or determining eligibility for benefits, I authorize
GMS to: (a) collect, store and use any personal information which I have provided to GMS or personal information obtained
pursuant to clause (b); and/or (b) obtain personal information about me (or any other person listed herein) from, or disclose
such personal information to: my Government Health Insurance Plan; the operator of any hospital, clinic or other health
facility; a doctor or other health care provider; any insurance company; or any other service provider or third party as
may be reasonably required for the purposes described above.
I warrant that neither I nor any person herein have any additional coverage through any insurer other than the information
listed herein and hereby authorize GMS to coordinate any eligible expenses with any additional insurer listed herein.
I understand that any misrepresentation, incorrect or concealed information or failure to fully complete all sections of
this form may void my coverage.
I declare that, if I am submitting on behalf of any person(s), I have the authority to submit on behalf of such person(s)
listed herein and confirm that each of the above declarations and authorizations are also provided on behalf of such person(s).
Please attach your scanned receipts.
- All claims must be submitted within 12 months from the date of service.
- Please retain original itemized receipts for 12 months from submission date, as
you may be requested to present them for audit purposes.
- Attach all receipts to this claim form.
- Include any required physician referrals or orders.
- Please accumulate at least $20 in total expenses before submitting a claim.