Medical expenses

Instructions

Step 1 : Fill out and sign the form. Step 2 : Gather original supporting documents. Step 3 : Send everything to the address indicated on the form.

Important

  • Keep copies of all correspondence for at least 12 months.
  • Originals will not be returned.

Certain expensive drugs, or drugs more likely to be misused, require prior authorization from Desjardins Insurance before you can be reimbursed.

To obtain applicable forms or get more information refer to the prior authorization drugs section.

Forms


Claim for Healthcare Benefits – Plan member – 19132A (PDF, 481 KB)

This form is used to submit claims for prescription drugs and other health related care and services:

  • drug expenses
  • vision care expenses
  • medical care expenses
  • paramedical services (chiropractor, massage therapist, physiotherapist, etc.)
  • therapeutic equipment and devices

Important:

Claims must be submitted within 12 months of incurring the expense. For a quick processing of your claim, and for certain types of expenses, you may use the e-claims services of our secure Member's web site. To make sure your claim is completed adequately, please refer to the following guidelines (PDF, 758 KB).


Request for Reimbursement of Brand Name Medications – Plan member – 12126E (PDF, 389 KB)

This form is used to request authorization for the reimbursement of brand name drugs when their generic equivalents cannot be taken due to medical reasons.

Important:

This form is only for plan members whose plans include mandatory generic substitution. One section of this form must be completed by the attending physician. The plan member is responsible for any fees charged for filling out the form.


Request for Reimbursement of a medication not included in the Dynamic Therapeutic Formulary (DTF) or of a Brand Name Medication – Plan Member – 13175E (PDF, 928 KB)

This form is used to request authorization for the reimbursement of drugs not included on the DTF and/or brand name drugs when their generic equivalents cannot be taken due to medical reasons.

Important:

This form is only for plan members covered by a tiered plan with DTF. One section of this form must be completed by the attending physician. The plan member is responsible for any fees charged for filling out the form.


Claim for Convalescent Care – Plan member – 98130E (PDF, 385 KB)

This form is used to submit a claim for homecare services if this coverage is offered under your policy.

Important:

One section of the form is filled out by the physician who recommended the convalescence period and another by health professionals consulted during the convalescence. The plan member is responsible for any fees charged for filling out the form.


Declaration of Dependent Children Aged 18 to 25 or 21 to 25 Inclusive (According to Contract Provisions) – Plan member – 19131A (PDF, 318 KB)

This form is used to report on or maintain the status of a dependent child who has reached the age of 18 or 21 (depending on the age limit stipulated in the policy).

Important:

This form is normally filled out and returned to us once a year at the beginning of each fall session. To learn more about the definition of dependent child, refer to your policy or contact your plan administrator.


Confirmation of a dependent child’s functional impairment – Plan member – 09296E (PDF, 548 KB)

This form is used to advise us if a dependent child has a functional impairment.

Important:

One section of this form is completed by the attending physician.


Direct Deposit and Electronic Notice Enrollment – Plan member – 07019E (PDF, 483 KB)

This form is used to request that health and dental claim payments be deposited directly into your bank account, and to receive email notification when your health or dental claims have been processed.

Important:

Please send us a VOID cheque. Direct deposit and electronic notice enrolment is possible via our secure Member's Web site.