HEALTH SPENDING ACCOUNT CLAIM FORM
CANADA REVENUE AGENCY REQUIRES YOU TO CLAIM ALL MEDICAL EXPENSES THROUGH YOUR PROVINCIAL AND
GROUP INSURANCE PLANS BEFORE PAYMENT CAN BE MADE FROM A HEALTH SPENDING ACCOUNT.
MEMBER INFORMATION
Certicate Number Client Number Last Name First Name
Address City Province Postal Code
Email Address / Phone Number
Has your address changed? Yes q No q
Some plans require address changes be requested through the employer only.
SERVICE RECIPIENT (PATIENT) INFORMATION
For additional service recipients, please use another claim form.
Service Recipient’s Name Birth Date (dd/mm/yyyy) Relationship to Member Total Amount Claimed ($)
COORDINATION OF BENEFITS
A. Are any benets provided under another Manitoba Blue Cross Plan? Yes q No q
If yes, please provide the certicate number of the other plan______________________________
B. Are any benets provided under any other insurance carrier Yes
q No q
If yes, please provide the following information:
Name of the other insurance carrier_______________________________ Policyholder name __________________________________
Eective date of coverage______________________________ Are all family members covered under this policy? __________________
If no, please indicate which members are covered:_____________________________________________________________________
What coverage does the other plan provide? q Ambulance q Dental q Health q Hospital q Prescription Drugs q Vision q HSA
TYPE OF REQUEST
q Process attached receipts
q Process all eligible expenses in my Health Spending Account
q Process the following types of expenses in my Health Spending Account:
q Ambulance q Hospital
q Dental q Prescription Drugs
q Health q Vision
If you have claimed any expenses with another insurance carrier, please submit the Explanation of Benets from that carrier.
AUTHORIZATION AND CONSENT
I certify that this claim is true and correct and incurred by me or my dependent as recognized by Canada Revenue Agency and all attached receipts have
been paid in full to the service provider and are medical expenses that are recognized as eligible with Canada Revenue Agency. I also certify that I am aware
of and have read the Authorization and Consent on the reverse side of this claim form.
Member or Service Recipient Signature__________________________________________ Date_____________________________________
(or Parent/Guardian)
Please see reverse for contact information and how to submit your claim.
Received Date
®*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, independently licensed by Manitoba Blue Cross.
†Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association. 2021-0826
HOW TO SUBMIT YOUR CLAIM
Online: mybluecross
@
account
at mb.bluecross.ca
Mail: PO Box 1046 Stn Main
Winnipeg MB R3C 2X7
In Person/ 599 Empress Street
Drop Box: Winnipeg, MB
Fax: 204.772.1231
Inquiries? Email through Contact Us at mb.bluecross.ca or phone 204.775.0151 or 1.888.596.1032 (toll free)
AUTHORIZATION & CONSENT
I understand that the personal information provided herein as well as any other personal information currently
held or collected in the future by Manitoba Blue Cross may be collected, used, or disclosed to administer the
terms of the group policy of which I am an eligible member, to develop and recommend suitable products and
services to me, and to manage the company’s business.
Depending on the type of coverage I carry, limited personal information may be collected from and/or released
to a third party. These third parties include other Blue Cross Plans, health care professionals or institutions,
health and life insurers, government and regulatory authorities, and other third parties when required to
administer the benets outlined in my policy or the group policy of which I am an eligible member. I understand
that Blue Cross may retain service providers inside and outside of Canada to assist them in their business
and further understand that my personal information may be subject to disclosure to law enforcement and
other authorities, where required by law, both inside and outside of Canada, when such information is in the
possession of Blue Cross or one of its authorized service providers.
I understand that I have provided my consent for Blue Cross to collect, use and disclose my personal
information as outlined in the Blue Cross Privacy Code. I understand that I may revoke my consent at any time;
however, if consent is withheld or revoked, the coverage may be denied or rescinded.
I understand why my personal information is needed and am aware of the risks and benets of consenting
or refusing to consent to its disclosure. For additional information regarding Manitoba Blue Cross’s privacy
policies I can contact Manitoba Blue Cross at 204.775.0151 or 1.800.873.2583 or mb.bluecross.ca should I
have questions as to the collection, use or disclosure of my personal information.
I authorize Manitoba Blue Cross to collect, use and disclose my personal information as described above.
