Forms

You can quickly and easily find all of the forms you are looking for on this page.

To find all the forms you may need, simply click on the tab that best describes you. Then click ‘More’ to download.

Advisor
Member
Provider
Sponsor

Administrative Forms
Claims Forms
New Group Setup
Special Authorization Forms
Specialized Forms/Questionnaires

Administrative Forms

Administration Manual – Health and Dental

User guide for administering health and dental benefit programs.

Benefit Guide – All

Generic employee booklet of health and dental programs highlights, usage guidelines and contact information.

Benefit Guide – Drug

Generic employee booklet of drug programs highlights, usage guidelines and contact information.

Claim Invoice – Plan

Invoice identifying claim detail by benefit line. Breakdown includes submitted and paid transaction volumes and expenditures.

Claim Invoice – Group Summary

Invoice identifying claim detail by benefit line. Breakdown includes submitted and paid transaction volumes and expenditures.

Enrollment Form

This form is to be completed when enrolling new employees or changing existing coverage information.

Explanation of Benefits (Sample)

Statement describing submitted and paid claim details by line of benefit, explanation of adjustments and/or rejections and address details.

Monthly Employee Roster – Sample

Billing statement listing insured individuals, their respective coverage, volumes and coverage status, premium information and taxes.

OAD Eligibility Form

This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.

Premium Billing Statement - Sample

Billing statement listing insured services, coverage volumes, coverage status, rate information and taxes.

Spending Account Specifications

Spending Account Deposit Input Specifications for HSSA or Wellness benefits.

Stop Loss SecurePak - Specific

Policy identifying Stop Loss coverage details and coverage exclusions.

Stop Loss SecurePak - Specific Plus

Policy identifying Stop Loss coverage details and coverage exclusions.

Stop Loss SecurePak - Aggregate

Policy identifying Stop Loss coverage details and coverage exclusions.

TPA Enrollment Form

Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.

Travel Health Policy

Policy identifying travel coverage details and coverage exclusions.

Web Connectivity Requirements – Existing Client

Document lists minimum hardware and software requirements for users of ClaimSecure web services.

Web Administration Manual – Health and Dental

User guide for managing web eligibility.

Web Connectivity Requirements – NEW client

Document lists minimum hardware and software requirements for users of ClaimSecure web services.

Claims Forms

Dental

This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Drug

This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Extended Health Care

This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Health Service Spending Account (HSSA)

This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Hospital

This form is to be completed when submitting a hospital claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

New Group Setup

Budgeted ASO Banking Form

This form must be completed for all clients requesting payment to be made on a monthly basis, for predetermined amounts. Reconciliation will occur on a predetermined basis.

Claim History Tape Specifications – Dental and EHC

An interactive document that contains previously paid claim detail and data format elements for electronic file submissions.

Eligibility Tape Specifications

An interactive document that contains member/dependant coverage details and data format elements for electronic file submissions.

Master Application

An interactive document that captures plan design details on Health, Dental and Life/disability coverage.

Quoting Criteria

Document containing a list of questions ClaimSecure requires in order to provide a quotation for services.

Stop Loss Application

Application to be completed by the plan sponsor when applying for Stop Loss coverage.

Travel Health Application

Application to be completed by the plan sponsor when applying for Out of Country travel health coverage.

Special Authorization Forms

Anti-obesity

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Erectile Dysfunction

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Specialty Drugs and Approval Guidelines

List of Specialty drugs that may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.

Standard

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Drug List

List of drugs that may be classified as “Requires Special Authorization” by the plan sponsor.

Specialized Forms/Questionnaires

Custom Knee Brace Questionnaire

This questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Hospital Bed Assessment Form

This questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Nursing Care Assessment Form

This questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Wheel chair Rental Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Administrative Forms
Claims Forms
Special Authorization Forms
Specialized Forms/Questionnaires

Administrative Forms

Benefit Guide

Generic employee booklet of health and dental programs highlights, usage guidelines and contact information.

Enrollment Form

This form is to be completed when enrolling new employees or changing existing coverage information.

Explanation of Benefits (Sample)

Statement describing submitted and paid claim details by line of benefit, explanation of adjustments and/or rejections and address details.

OAD Eligibility Form

This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.

Claims Forms

Cost Plus

This form is to be completed for all claims deemed payable by an authorized plan member, in accordance with Federal and Provincial guidelines.

Dental

This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Drug

This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Extended Health Care

This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Health Service Spending Account (HSSA)

This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Hospital

This form is to be completed when submitting a hospital claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Vision

This form is to be completed when submitting a vision claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Special Authorization Forms

Anti-obesity

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Drug and Approval Guidelines

List of drugs that may be classified as “Requires Special Authorization” by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.

Erectile Dysfunction

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Specialty Drugs and Approval Guidelines

List of Specialty drugs that may be classified as "Requires Special Authorization" by the plan sponsor – plan members may download this list and provide it to their Healthcare Providers.

Standard

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Specialized Forms/Questionnaires

Custom Knee Brace Questionnaire

This questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Hospital Bed Assessment Form

This questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Nursing Care Assessment Form

This questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Wheel chair Rental Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Administrative Forms
Claims Forms
Special Authorization Forms
Specialized Forms/Questionnaires

Administrative Forms

Pharmacy Provider Agreement and Information

Form and Agreement to be signed by pharmacy in order to connect and transmit real time drug claims to ClaimSecure.

Provider Connectivity Manual

User guide to assist pharmacies on how to connect and transmit real time drug claims to ClaimSecure.

Claims Forms

Dental

This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Drug

This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Extended Health Care

This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Health Service Spending Account (HSSA)

This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Hospital

This form is to be completed when submitting a hospital claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Vision

This form is to be completed when submitting a vision claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Special Authorization Forms

Drug List

List of drugs that may be classified as “Requires Special Authorization” by the plan sponsor.

Specialized Forms/Questionnaires

Custom Knee Brace Questionnaire

This questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Hospital Bed Assessment Form

This questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Nursing Care Assessment Form

This questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Wheel chair Rental Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Administrative Forms
Claims Forms
New Group Setup
Special Authorization Forms
Specialized Forms/Questionnaires

Administrative Forms

Administration Manual – Health and Dental

User guide for administering health and dental benefit programs.

Benefit Guide – All

Generic employee booklet of health and dental programs highlights, usage guidelines and contact information.

Benefit Guide – Drug

Generic employee booklet of drug programs highlights, usage guidelines and contact information.

Claim Invoice – Plan

Invoice identifying claim detail by benefit line. Breakdown includes submitted and paid transaction volumes and expenditures.

Claim Invoice – Group Summary

Invoice identifying claim detail by benefit line. Breakdown includes submitted and paid transaction volumes and expenditures.

Enrollment Form

This form is to be completed when enrolling new employees or changing existing coverage information.

Explanation of Benefits (Sample)

Statement describing submitted and paid claim details by line of benefit, explanation of adjustments and/or rejections and address details.

Monthly Employee Roster – Sample

Billing statement listing insured individuals, their respective coverage, volumes and coverage status, premium information and taxes.

OAD Eligibility Form

This form is to be completed when enrolling a new over-age-dependant or changing existing coverage information.

Premium Billing Statement - Sample

Billing statement listing insured services, coverage volumes, coverage status, rate information and taxes.

Spending Account Specifications

Spending Account Deposit Input Specifications for HSSA or Wellness benefits.

Stop Loss SecurePak - Specific

Policy identifying Stop Loss coverage details and coverage exclusions.

Stop Loss SecurePak - Specific Plus

Policy identifying Stop Loss coverage details and coverage exclusions.

Stop Loss SecurePak - Aggregate

Policy identifying Stop Loss coverage details and coverage exclusions.

TPA Enrollment Form

Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information.

Travel Health Policy

Policy identifying travel coverage details and coverage exclusions.

Web Connectivity Requirements – Existing Client

Document lists minimum hardware and software requirements for users of ClaimSecure web services.

Web Administration Manual – Health and Dental

User guide for managing web eligibility.

Web Connectivity Requirements – NEW client

Document lists minimum hardware and software requirements for users of ClaimSecure web services.

Claims Forms

Dental

This form is to be completed when submitting a dental claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Drug

This form is to be completed when submitting a drug claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Extended Health Care

This form is to be completed when submitting a major medical claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Health Service Spending Account (HSSA)

This form is to be completed when submitting an HSSA claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Hospital

This form is to be completed when submitting a hospital claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

Vision

This form is to be completed when submitting a vision claim for reimbursement. Be sure to include the original receipt along with the completed claim form.

New Group Setup

Budgeted ASO Banking Form

This form must be completed for all clients requesting payment to be made on a monthly basis, for predetermined amounts. Reconciliation will occur on a predetermined basis.

Claim History Tape Specifications – Dental and EHC

An interactive document that contains previously paid claim detail and data format elements for electronic file submissions.

Eligibility Tape Specifications

An interactive document that contains member/dependant coverage details and data format elements for electronic file submissions.

Master Application

An interactive document that captures plan design details on Health, Dental and Life/disability coverage.

Stop Loss Application

Application to be completed by the plan sponsor when applying for Stop Loss coverage.

Travel Health Application

Application to be completed by the plan sponsor when applying for Out of Country travel health coverage.

Special Authorization Forms

Anti-obesity

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Erectile Dysfunction

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Standard

This claim form is to be completed when an individual is applying for a drug that requires clinical review prior to approval.

Drug List

List of drugs that may be classified as “Requires Special Authorization” by the plan sponsor.

Specialized Forms/Questionnaires

Custom Knee Brace Questionnaire

This questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Hospital Bed Assessment Form

This questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Nursing Care Assessment Form

This questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval.

Wheel chair Rental Questionnaire

This questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval.