MANITOBA INTERNATIONAL STUDENT HEALTH PLAN
MEDICAL SERVICES CLAIM FORM
PLEASE READ CAREFULLY BEFORE COMPLETING THE CLAIM.
• PLEASE ATTACH ORIGINAL ITEMIZED RECEIPTS/INVOICES. KEEP COPIES FOR YOUR RECORDS.
• ENSURE THE FIRST AND LAST NAME RECORDED ON THIS FORM APPEAR EXACTLY AS THEY DO ON YOUR MISHP COVERAGE CARD.
• CLAIMS MUST BE RECEIVED IN OUR OFFICE WITHIN 6 MONTHS OF THE DATE OF SERVICE.
AUTHORIZATION AND CONSENT
I have read and understood the Authorization & Consent on the reverse side of this claim form. I conrm this claim is true and correct and that the
service recipient is eligible for coverage per the agreement in place. I understand that the charges listed may not be covered by or may exceed my policy
benets. I understand that I am nancially responsible to the provider for the cost of the treatment(s).
Service Recipient Signature________________________________________________ Date______________________________________________
(or Parent/Guardian for dependant children)
Please see reverse for contact information and how to submit your claim.
Received Date
Certicate Number Client Number Birth Date (DD/MM/YYYY)
Medical Coverage Identication (MCI) Number Are any expenses the result of an accident?
Yes No If Yes, please complete the following:
Last Name on MISHP Card First Name on MISHP Card Where did the accident occur?
Work Vehicle Other
Address (while attending University) Accident details: (if extra space is required, attach an additional page)
City Province Postal Code Email Address
q
8093
q q
q
q q
q q
PROVIDER INFORMATION
Billing Number Type of Provider
Last Name First Name Address
City Province Postal Code Telephone Number
q q
CLAIM DETAILS
Please complete these required elds.
(TO BE COMPLETED BY THE PROVIDER OF SERVICE OR ATTACH AN ITEMIZED RECEIPT OR INVOICE)
Certain taris require additional information. Please complete all relevant elds.
Do you have medical coverage from your country of origin while studying in Canada?
Service Date
(DDMMYYYY)
Tari Code
ICD
(Diagnosis
Code)
Billed
Amount
Referring
Provider
Facility # Start Time Stop Time
#
Serv
Ana
Units
Bilat
Indic
Split
Ind
# of
Pts
I0
Yes No
ISSUE PAYMENT TO PROVIDER STUDENT
MBC 1575-75M-07/2018
AUTHORIZATION & CONSENT
I understand that the personal information and personal health information provided herein as well as any
other personal information and personal health information currently held or collected in the future by Manitoba
Blue Cross may be collected, used, or disclosed to administer the terms of the 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 or personal health information may
be collected from and/or released to a third party. These include other Blue Cross organizations, licensed
physicians and/or any other healthcare professionals or institutions, health and life insurers, government and
regulatory authorities, and other third parties when required to administer the benets outlined in the 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 and personal health information is needed and am aware of the risks and benets of
consenting or refusing to consent to its disclosure. For additional information regarding Blue Cross’s privacy
policies as to the collection, use, or disclosure of my information, I may contact Blue Cross at 204.775.0151 or
1.888.596.1032 or mb.bluecross.ca.
I understand Studentcare will collect, use, and disclose my personal information for the purposes of managing
eligibility for coverage under the Manitoba International Student Health Plan. To learn more about their privacy
policies, I may contact Studentcare at [email protected].
®*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. 2022-0805
HOW TO SUBMIT YOUR CLAIM
Email: [email protected]
Mail: PO Box 1046 Stn Main
Winnipeg MB R3C 2X7
In Person/ 599 Empress Street
Dropbox: Winnipeg, MB
Fax: 204.788.5599
Inquiries? Email through Contact Us at mb.bluecross.ca or phone 204.788.6800 or 1.888.596.1032 (toll free)
