am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this information
may be seen by the cardholder.
By signing this claim form and/or submitting actual receipts, I agree that the information provided is complete and accurate. I understand that the information
provided by me to Green Shield Canada about myself and my dependents, will be used by Green Shield Canada for claims adjudication and any other services
necessary in the administration of our benefits which may include the exchange of information with other parties to administer this benefit claim.
I further authorize Green Shield Canada to obtain and exchange information with other parties, such as health practitioners or insurers, in order to confirm the
accuracy of the submitted claim(s) information. In the event of suspected fraudulent activity pertaining to claims submitted on behalf of myself and/or my
dependents, I acknowledge and agree to the disclosure of this information to relevant parties, such as the Plan Sponsor, regulatory and law enforcement agencies.