Claim Form

Agent: ________________

Name of Plan (Employer):

Employee Name: __________________________

Employee Mailing ___________________________________________

Address (to mail cheque to)

___________________________________________

Claims

Patient Name _____________ Relationship to Employee ____________

Date of Service	Description of Service	Amount
	Total Claim
	To Be completed by Employer only:
	Add: Administration Fee of 10%
	Add: Processing Charge* (if applicable)
	Add: 7% GST on Administration Fee & Processing Charges Only
	Total Due Make cheque payable to Private Health Solutions Corporation.

* If total claim is less than $500, there is an additional $10 processing charge.

See Instructions for Completion on Reverse

I certify that the information on this form is correct and complete to the best of my knowledge.

___________________________ ________________

Signature Date
CLAIMS PROCEDURES

1. Each employee submitting a claim should use a separate form. Preprinted CLAIM FORMS will be supplied by Private Health Solutions Corporation.

2. Ensure that all original receipts are enclosed with your CLAIM FORM. For prescription drugs the receipt will be marked “Original Tax Receipt”. If you are claiming dental expenses, please have your dentist complete a Standard Dental Claim Form (available from your dentist).

3. Upon completion of this CLAIM FORM, submit to the Employer for completion of the section on Administration Fees.

Employer: For submissions including more than 1 employee,

please use CLAIM SUMMARY FORM to calculate the

Administration Fee and GST. Please enclose all supporting

employee CLAIMS FORMS along with your CHEQUE PAYABLE to Private Health Solutions Corporation.

For submissions including only 1 employee, the Administration

Fee and GST may be calculated on the CLAIM FORM.

4. The Employer will then forward the CLAIM FORM to Private Health Solutions Corporation for processing. A cheque will be sent directly to you at the address provided on the CLAIM FORM.