Group Benefits Extended Health Care Claim

Page 1 of 2

Patient's name

Yes No

1 Plan member information

Group Benefits

Extended Health Care Claim

To be completed by the plan member unless otherwise indicated. Original receipts must be attached for all expenses. (Please attach to the

back of this form.) Please retain copies for your files as original receipts will not be returned.

The Manufacturers Life Insurance Company

GL5112E(87220) (03/2012) CII

2 Patient information

Complete for all expenses.

Use one line per patient.

Plan contract number

Plan member name (first, middle initial, last) Birthdate (dd/mmm/yyyy)

Plan member certificate number Plan sponsor

Plan member address (number, street and apt.) City or town Postal codeProvince

Are these expenses eligible for coverage under any type

of workers' compensation board?

Are you, your spouse or dependants covered under any other plan for the expenses being claimed?

If "Yes," please retain photocopies of all receipts submitted with this claim for

submission to your secondary carrier. If this is your first claim, or if information has

changed, please provide the following:

Spouse's date of birth

(dd/mmm/yyyy)

Name of spouse's insurance company Spouse's plan member

certificate number

Spouse's plan contract number

Yes No

Receive your claim payments up to 70% faster with direct deposit and enjoy the convenience of seeing

your claim statements online.

• Go to www.manulife.ca/groupbenefits and register for the plan member secure site

• Once you've registered, or if you're already registered, log into the secure site and select

Direct deposit for claims from the menu to the left of the screen

• Enter your banking information

Date of birth

(dd/mmm/yyyy)

(1st Claim only)

Relationship to

plan member

(1st Claim only)

School and city

If employed,

hrs worked

per week

and electronic claim

statements

3 Prescription drug

expenses

4 Practitioner's/

Paramedical expenses

(e.g. chiropractor, massage

therapist, physiotherapist, etc.)

• Attach your prescription drug receipts to the back of this form.

• All receipts must contain the drug identification number (D.I.N.) and the name of the prescription drug.

• You are not required to list this information on the form.

For practitioner/paramedical expenses please attach an itemized statement and/or receipt stating:

• patient name, • length of visit,

• name of practitioner • charge for treatment,

• type of practitioner, • date last paid by provincial plan (if applicable) and

• date of service, • licence and/or registration number.

If for psychotherapy, please indicate type (individual, family, group, marriage) on your receipt.

Check here to use your Health Care Spending Account (HCSA) to reimburse any unpaid portion of

this claim.

(If the patient has health coverage under another plan, you must submit any unpaid amount from this claim to

that plan before using your HCSA.)

HCSA contract number

Complete if patient is a student 18 or older

87220 University of Western Ontario

87221

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Yes No

5 Equipment and appliance

expenses

Indicate the activities requiring the use of this item.

For equipment and appliance expenses Manulife Financial requires a written recommendation from

the prescribing physician, including diagnosis, and a copy of the provincial plan statement of payment

(if applicable).

Duration equipment is required.

Date (dd/mmm/yyyy)

The Manufacturers Life Insurance Company

GL5112E(87220) (03/2012) CII

From

Date (dd/mmm/yyyy)

Has rental equipment been returned?

6 Claims confirmation

NOTE - ORIGINAL RECEIPTS

must be attached for all

expenses.

Total amount of ALL receipts submitted

I certify that I, my spouse and/or my dependants of minor or major age ("Dependants"), have received

all goods or services claimed and that the information provided for this claim is true and complete.

I authorize

Manulife Financial ("Manulife") to collect, use, maintain and disclose personal information

relevant to this claim ("Information") for the purposes of Group Benefits plan administration, audit and

the assessment, investigation and management of this claim ("Purposes"). I am authorized

by my

Dependants to disclose and receive their Information, for the Purposes. I authorize

any person or

organization with Information, including any medical and health professionals, facilities or providers,

professional regulatory bodies, any employer, group plan administrator, insurer, investigative agency,

and any administrators of other benefits programs to collect, use, maintain and exchange this

information with each other and with Manulife, its reinsurers and/or its service providers, for the

Purposes. I authorize

the use of my Social Insurance Number ("SIN") for the purposes of identification

and administration, if my SIN is used as my plan member certificate number. I agree

a photocopy or

electronic version of this authorization is valid. I understand

that Manulife's Privacy Policy and Privacy

Information Package are available at www.manulife.ca/groupbenefits, or from my Plan Sponsor.

Signature of plan member Date signed (dd/mmm/yyyy)

Any Information provided to or collected by Manulife in accordance with this authorization, will be kept

in a Group Benefits health file. Access to your Information will be limited to:

• Manulife employees, representatives, reinsurers, and service providers in the performance of their

jobs;

• Persons to whom you have granted access; and

• Persons authorized by law.

You have the right to request access to the personal information in your file, and, where appropriate, to

have any inaccurate information corrected.

7 Mailing instructions

Please mail your completed claim form and receipts to the address below.

MANULIFE FINANCIAL GROUP BENEFITS

HEALTH CLAIMS

PO BOX 1653

WATERLOO ON N2J 4W1

Please sign here