Claim Submission Form

Use this form to submit a health or dental claim online

To submit a travel or StudentPlan claim, please complete a Travel Emergency Medical Claim Form. To submit an Immigrants & Visitors to Canada claim please complete an Immigrants & Visitors to Canada Emergency Medical Claim Form. Please note travel, Immigrants & Visitors to Canada, and StudentPlan claims cannot be submitted online. For more information on submitting claims click here.

Personal Information
   
     
Address
Would you like to update your address?
Other Coverage Information
Have there been any changes to your other coverage since your last claim?
This includes cancellation of coverage (if so, please make sure you include the End Date of Coverage), any new coverage, or changes to an existing coverage (for example adding or removing a dependant).  
Claims Information
Are any of the claims due to a work related accident or sickness?   Are any of the claims due to a motor vehicle accident?  
First Name GMS ID Date of Birth Type of Expense
(i.e., ambulance, crutches, etc.)
No. of Claims Total Amount of Claims
 
   
 
   
 
   
 
   
 
   
 
   
Total
Declaration

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).

 

Attachments

Please attach your scanned receipts.

 
Please remember the following when submitting claims:
  • 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.