Member Forms

You can quickly and easily find all of the forms you are looking for on this page. Either browse through the list of forms below or use the “Search Forms” field to do a keyword search of all forms. Once you’ve found your form you can download it in PDF format using the “download” link.

Administrative Forms

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

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.

Wellness

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

Drug Plan Enhancements

Formulary Select Drug List

List of Formulary Select drugs and alternatives in the same therapeutic class.

Frequently Asked Questions - Trillium and the Trillium Coordination program

Answers to frequently asked questions relating to Trillium and how ClaimSecure coordinates with this provincial drug program.

Special Authorization Forms

Frequently Asked Questions

Answers to frequently asked questions relating the Special Authorization process.

Anti-obesity

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

Special Authorization Drug List

List of all drugs that may be classified as “Requires Special Authorization” by the plan sponsor under our Managed Plans, including specialty medication.

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 only. These drugs 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.

No Substitution Request

This claim form should be completed when an individual whose plan design includes mandatory generic is applying for coverage for the full cost of the brand name drug.

Coverage Navigation Service Enrolment

This form is to be completed when an individual is accessing the coverage navigation service for assistance applying to government and/or manufacturer sponsored programs for Specialty Drug coverage.

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.

Wheelchair 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.

Oxygen Concentrator Assessment Form

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