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AUTHORIZATION
AND RELEASE FORM
Europ Assistance USA
4330 East West Highway Suite 1000
Bethesda, MD 20814
Fax: 1-202-466-2919
Address
The Authorization and Release is a 2-page form that will be forwarded to you once Europ
Assistance (Sun Life’s Travel Benefit Provider) receives your out-of-Province/out-ofCountry claim for emergency medical expenses. Page 2 requires your signed authorization
and release.
Date
Contract # / Certificate # :
Claim Number #: W-M
Dear Mr./Mrs./Ms.:
Please be informed that upon receipt of your medical claims, we will process them on behalf of Sunlife Financial Canada.
Due to the fact that we submit some claims to the Government Health Insurance Plan (GHIP), the enclosed
Authorization and Release Form will allow us to coordinate the payment of your medical claims. Please complete the
form, and sign it (the person who received medical treatment must sign the form).
We ask all medical providers to submit the medical claims directly to us. However, if you had to pay at the time you
received medical treatment, please attach all original receipts, bills and medical information and return it to the
Bethesda, MD address shown at the top of this page.
GHIP will only accept documents that are signed by the patient. Parents can sign for minors. An authorized
representative can also sign the forms if he/she holds a valid power of attorney.
Please be sure to include the PATIENT’s Health Insurance Number (with any applicable version codes) on the forms, as
well as a photocopy of the card itself. Any incomplete or incorrect information will delay submission.
If you have any questions, please contact our office at 1.800.511.4610.
Sincerely,
Europ Assistance USA, Inc.
Enclosure
This document, any attachment and the information contained therein ("this message") may contain information that is privileged, proprietary, confidential and exempt
from disclosure and are intended solely for the use of the addressee(s). If you have received this message in error please send it back to the sender and delete it. If you are
not the intended recipient, you are notified that unauthorized publication, use, dissemination or disclosure of this message, either in whole or in part, is strictly prohibited.
------------------------------------------------------------------------------------------------Ce document et tous les fichiers joints ainsi que les informations contenues dans ce message (ci après "ce message”), peuvent contenir des renseignements de caractère
privé ou confidentiel et sont destinés exclusivement à l'usage de la personne à laquelle ils sont adressés. Si vous avez reçu ce message par erreur, merci de le renvoyer à
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sont strictement interdites.
AUTHORIZATION
AND RELEASE FORM
Policy Holder’s Name:
EA-USA File # W-M
Patient’s Name:
Date: state today’s date
AUTHORIZATION AND RELEASE
I, state your name, irrevocably direct and authorize British Columbia Medical Services Plan (MSP) to make payment in
respect of my claim for out-of-country health services during my trip from ____/____/____ to ____/____/____ in state
the city and country where the expense was incurred, to Europ Assistance USA, Inc. (EA-USA) directly and I hereby release
MSP, upon payment to EA-USA, from any further claim or cause of action in connection therewith.
I hereby consent and authorize MSP to directly or indirectly collect information contained in the claim and source
documents pursuant to Section 39(1) of the Freedom of Information and Protection of Privacy Act, and Section 4(2)(f)
of the Health Insurance Act.
I consent to the disclosure by MSP to EA-USA of such personal information as may be necessarily required for the
processing of my claim for out-of-country health services, including the details of any duplicate payment previously
made directly to me.
Other than insurance provided by your provincial plan and SUN LIFE ASSURANCE COMPANY OF CANADA do you
have any other medical insurance coverage? (Please mark "X" where appropriate)
Yes
No
If yes, please provide the name of the insurance carrier, policy number, and certificate number, and the name of the
member or cardholder under the other plan:
Insurance carrier: _____________________ Policy #: _____________________ Identification #: ____________________
If you have indicated yes and are covered under another plan, provide the requested information above. If you are unsure of the
plan details, contact the administrator of that plan for more information.
By signing below,
a)
I acknowledge and accept that EA-USA, acting on behalf of SUN LIFE ASSURANCE COMPANY OF
CANADA, may recover additional insurance carrier monies that have been advanced to others on my behalf. I
further authorize any benefits paid or payable by another insurance carrier in respect of this claim to be
assigned in whole or in part to SUN LIFE ASSURANCE COMPANY OF CANADA.
b)
I authorize SUN LIFE ASSURANCE COMPANY OF CANADA, its agents, service providers and reinsurers to
use and exchange information needed for underwriting, administration and adjudicating claims under this Plan
with any person or organization who has relevant information pertaining to this claim including health
professionals, institutions, investigative agencies, insurers and reinsurers. I understand that information about
me pertaining to this claim may be reviewed in the event that this Plan is audited.
c)
I understand that if I am a dependant under this Plan, the Member will have access to information about me
relating to this claim in connection with the administration of this Plan.
I understand that, as a courtesy to me, EA-USA, on behalf of SUN LIFE ASSURANCE COMPANY OF CANADA, may
pay medical and other providers in full for authorized expenses, prior to seeking payment from the appropriate
provincial plan or other insurer. I also understand that EA-USA may submit the claim to my provincial plan for
consideration and reimbursement. For those provinces whose plans do not allow third party assignment of benefits, I
agree to reimburse EA-USA the full amount received by me from the provincial plan and to provide EA-USA with all
necessary, relevant and applicable documentation from the provincial plan concerning any payments or denials of
claims.
This document, any attachment and the information contained therein ("this message") may contain information that is privileged, proprietary, confidential
and exempt from disclosure and are intended solely for the use of the addressee(s). If you have received this message in error please send it back to the
sender and delete it. If you are not the intended recipient, you are notified that unauthorized publication, use, dissemination or disclosure of this message,
either in whole or in part, is strictly prohibited.
------------------------------------------------------------------------------------------------Ce document et tous les fichiers joints ainsi que les informations contenues dans ce message (ci après "ce message”), peuvent contenir des renseignements
de caractère privé ou confidentiel et sont destinés exclusivement à l'usage de la personne à laquelle ils sont adressés. Si vous avez reçu ce message par
erreur, merci de le renvoyer à son émetteur et de le détruire. Toute diffusion, publication, totale ou partielle ou divulgation sous quelque forme que se soit
non expressément autorisées de ce message, sont strictement interdites.
I consent to the disclosure by my Canadian physician to EA-USA of such personal information as may be necessary for
the processing of my claim for out-of-country health services.
I certify that the above statements are true to the best of my knowledge.
__________________________________________
Signature of Patient (if minor, parent please sign)
__________________________________________
Patient's Date of Birth
__________________________________________
Patient’s Home Address
__________________________________________
Patient’s Home Telephone # w/area code
__________________________________________
Employer
__________________________________________
Work Telephone # w/area code
_________________________________________
Patient's British Columbia Medical Services Plan #
(This is the 10-digit number beginning with the number 9 indicated on your BC Care Card)
This document, any attachment and the information contained therein ("this message") may contain information that is privileged, proprietary, confidential
and exempt from disclosure and are intended solely for the use of the addressee(s). If you have received this message in error please send it back to the
sender and delete it. If you are not the intended recipient, you are notified that unauthorized publication, use, dissemination or disclosure of this message,
either in whole or in part, is strictly prohibited.
------------------------------------------------------------------------------------------------Ce document et tous les fichiers joints ainsi que les informations contenues dans ce message (ci après "ce message”), peuvent contenir des renseignements
de caractère privé ou confidentiel et sont destinés exclusivement à l'usage de la personne à laquelle ils sont adressés. Si vous avez reçu ce message par
erreur, merci de le renvoyer à son émetteur et de le détruire. Toute diffusion, publication, totale ou partielle ou divulgation sous quelque forme que se soit
non expressément autorisées de ce message, sont strictement interdites.