Claim Information
Step 4 of 4
Using your original receipts, enter the information below for each individual claim.
  • Select your provider from the drop-down list. If the provider is not in the list, select the new provider button below to add the provider.
  • complete the claim information
  • when you have finished entering your claim information, click continue
  • For further explanation on what should be entered into the field click on the appropriate column heading.

For further explanation on what should be entered into the field click on the appropriate column heading.



Claim information:
 
Provider
 
Type of Service
Service Date
dd/mm/yyyy
Claim
Amount
(xxx.xx)
  Initial
Visit
COB
(Y/N)
  COB
Amount
(xxx.xx)
 
        $     $  
        $     $  
        $     $  
        $     $  
        $     $  
        $     $  
        $     $  
        $     $  
$
270.00
 
 

 

Note
You can submit up to eight paramedical expenses on one claim. Once you have completed your first claim, if you have more services to submit, click submit another claim at the end of this session.
 
You can read more about your and the types of services you can claim.
GBM-E0947
 

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