I certify that I have not claimed and will not claim these expenses under any other insurance plan (unless indicated above) and that all information contained herein is correct.
I hereby authorize any health care providers to release to Medavie Blue Cross any information that relates or supports claims submitted on my behalf and certify that the information given is true, correct and complete
to the best of my knowledge.
I understand that the personal information provided herein, as well as any other personal information currently held or collected in the future by Medavie Blue Cross and/or Blue Cross Life Insurance Company of
Canada, may be collected, used or disclosed to administer the terms of my policy or the group policy of which I am an eligible member, to recommend suitable products and services to me and to manage Blue Cross’s
business. Depending on the type of coverage I carry, limited personal information may be collected from and/or released to a third party. These third parties include other Blue Cross organizations, health care
professionals or institutions, life and health insurers, government and regulatory authorities, the member of any policy under which I am a participant and other third parties when required to administer and
manage the benefits outlined in the policy of which I am an eligible member.
I understand that my personal information will be kept confidential and secure. I understand that I may revoke my consent at any time, however, in some instances doing so may prevent Medavie Blue Cross from
providing me with the requested coverage or benefits. I understand why my personal information is needed and I am aware of the risks and benefits of consenting or refusing to consent to its disclosure.
I authorize Medavie Blue Cross to collect, use and disclose my personal information as described above.