Your claim has been submitted and will be processed within five business days. You will receive an email notice when it is processed. You can print an online claims statement containing the confirmation number and all of the information submitted with this claim. If you are unable to print these documents now, they can be accessed later from our full site by selecting 'Online claim status' from the claims menu.
You can get through to a customer service representative or take advantage of our self-service interactive voice response (IVR) capabilities by calling 1-800-268-6195 . Representatives are available Monday to Friday, from 8:00AM to 8:00PM EST.
Sign and date, and include with your claim statement, receipt and supporting documentation
I certify that I, my spouse and/or my dependants of minor or majorage (Dependants), have received all goods or services claimed and that the informationprovided for this online claim session is true and complete. I authorize Manulife Financial (Manulife) to collect, use, maintain and disclose personalinformation relevant to this online claim (Information) for the purposes of GroupBenefits plan administration, audit and the assessment, investigation and managementof this online claim (Purposes). I am authorized by myDependants 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 planadministrator, insurer, investigative agency, and any administrators of other benefitsprograms to collect, use, maintain and exchange this Information with each otherand with Manulife, its reinsurers and/or its service providers, for the Purposes. I agree that both my online claim and my coverage may bedenied or terminated as a result of my providing false, incomplete, or misleadingInformation. I agree to refund any monies or overpayments that I may owe to Manulife in accordance with the provisions of the Group Benefitsplan with Manulife, and I authorize Manulife to deduct suchmonies from my future claims. I authorize the use of my SocialInsurance Number (SIN) for the purposes of identification and administration,if my SIN is used as my plan member certificate number. I agree a photocopy, facsimile or electronic version of this authorization shall be as validas the original. I understand that Manulifes Privacy Policyand Privacy Information Package are available at www.manulife.ca/groupbenefits , or from my Plan Sponsor.
Signature of plan member:
Date Signed :
Any Information provided to or collected by Manulife in accordance with this online authorization, will be kept in a Group Benefits health file. Access to your Information will be limited to:
You have the right to request access to the personal information in your file, and, where appropriate, to have any inaccurate information corrected.
We cannot find the form you are looking for. Please contact the customer service for further information