SUNLIFE Consent and Authorization for Electronic Claims Submission and Assignment of Benefits Form

Important Note:

Plan Members must complete this form, even if your patient or customer is the Plan Member’s dependent.
We refer to the Provider as “you” or “Provider”.
You keep the completed form on file for verification purposes for the later of (i) 6 years following the last service date or (ii) such longer period as required by applicable law or the regulations and professional standards of your regulatory body, college or association.

Plan means a group benefits plan or an individual policy of insurance. Plan Member means for group plans, the eligible member (e.g. for an employer group plan, this is the employee) responsible for the group benefits coverage. For individual insurance policies, the Plan Member is the policyholder. Plan Members’ dependents are eligible for coverage. Dependents are the Plan Member’s spouse or children. Plan Sponsor is the policyholder of an insured or self-insured group benefits plan. For example, for Plans covering employees, the Plan Sponsor is the Plan Member’s employer. Provider refers to licensed or qualified paramedical practitioner, ophthalmologist or optometrist providing medical services or goods. A Provider may be:

an organization, such as a facility or clinic, submitting claims on behalf of one or more healthcare practitioners; or
an individual responsible for their own billing.

In the Sun Life Electronic Claims Submission Agreement, we refer to the above as a Healthcare Practice and Independent Healthcare Provider respectively.

The patient or customer is the Plan Member(Required)

Yes

1. Plan Member information (Complete this if the patient or customer is the Plan Member)

Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address City Province Postal Code

Phone Number(Required)

Email(Required)

Contract number(Required)

Member ID(Required)

2. Patient or Customer information (Complete this if the patient or customer is not the Plan Member)

Name(Required)

First Last

Address(Required)

Street Address City Province Postal Code

Do you have second/another benefits plans?(Required)

Yes

3. Second/another benefits plans information

Name(Required)

First Last

DOB(Required)

Insurance Company(Required)

Contract number(Required)

Member ID(Required)

4. Provider/facility information

Vitality Massage and Facial Spa Tel:(905) 953-8688 Address: 559 Steven Court, Unit 13, Newmarket. On L3Y 6Z3 Email: info@vitalitymassageandspa.ca License Number: 789755816RT0001

5. Consent and Authorization for Electronic Claims Submissions

Consent(Required)

I authorize Provider to:

• electronically submit claims (eClaims) for healthcare goods, supplies or services for me or my dependent(s) to Sun Life
Assurance Company of Canada (Sun Life) on my behalf and on behalf of my dependents
o for the purposes set out below (see The Purposes) and
o to the relevant parties also set out below (see Relevant Parties).
• disclose information about the e-claim (including personal health information in the Provider’s files) to Sun Life.
For any eClaims made on behalf of my dependents and for the purposes set out in this form, I confirm that my dependents
authorized me to consent to the disclosure of their personal information to Sun Life.
The Purposes
I consent and agree that Sun Life and its reinsurers may collect, use and disclose the eClaims information to:
• adjudicate, review and audit eClaims;
• investigate any suspect claims involving potential fraud or plan abuse (“suspect claims”); and
• underwrite and administer the Plan
For suspect claims, I consent and agree that Sun Life and its reinsurers may also investigate claims to assess, detect and
prevent potential fraud or plan abuse.
Relevant parties
I also consent and agree that Sun Life and its reinsurers may collect, use and disclose the eClaims information with
relevant parties. These parties include persons or organizations having relevant information and a need to know about the
eClaim including:
• the Provider or other health practitioners;
• clinics, facilities, hospitals or other institutions; and
• other insurers.
For suspect claims, I further consent and agree that Sun Life and its reinsurers may collect, use and disclose eClaims
information with relevant parties that include:
• investigative agencies and the police
• regulatory bodies or associations
• government organizations
• medical suppliers
• other insurers
• my Plan Sponsor.
Overpayments
If there is an overpayment, I authorize:
• the recovery of the full amount of the overpayment from any amount payable to me under the Plan; and
• Sun Life to collect, use and disclose information about the eClaims with collection agencies.
General Information
I also understand that information pertaining to eClaims may be reviewed if the Plan is audited.
Any reference to Sun Life, reinsurers or the Plan Sponsor includes their agents and service providers.
A photocopy or electronic version of this authorization is as valid as the original, and remains in effect for the continued
administration of the Plan.

Signature(Required)

(If under 18 years of age, the signature of the member is required)

Print Name(Required)

Date(Required)

5. Assignment of Benefits

Signature(Required)

(If under 18 years of age, the signature of the member is required)

Print Name(Required)

Date(Required)

6. Respecting your privacy

Respecting your privacy is a priority for the Sun Life group of companies. We keep in confidence personal information about you and the products and services you have with us to provide you with investment, retirement and insurance products and services to help you meet your lifetime financial objectives. To meet these objectives, we collect, use and disclose your personal information for purposes that include: underwriting; administration; claims adjudication; protecting against fraud, errors or misrepresentations; meeting legal, regulatory or contractual requirements; and we may tell you about other related products and services that we believe meet your changing needs. The only people who have access to your personal information are our employees, distribution partners such as advisors, and third-party service providers, along with our reinsurers. We will also provide access to anyone else you authorize. Sometimes, unless we are otherwise prohibited, these people may be in countries outside Canada, so your personal information may be subject to the laws of those countries. You can ask for the information in our files about you and, if necessary, ask us in writing to correct it. To find out more about our privacy practices, visit www.sunlife.ca/privacy. Questions? Please visit www.sunlife.ca or call our toll-free number 1-800-361-6212 any business day from 8 a.m. to 8 p.m. ET.