EMERGENCY TRAVEL MEDICAL CLAIM FORM
The attached claim form must be completed in full, signed, and returned to our office as soon as possible. The
receipt of your completed forms will enable us to begin the assessment of your claim.
HOW TO COMPLETE YOUR EMERGENCY HOSPITAL & MEDICAL INSURANCE CLAIM FOR
CANADIANS
SECTION A – CLAIMANT INFORMATION
This section allows us to verify the claimant and policy information. If you contacted ACM to initiate your case,
much of this section will be pre-populated. If necessary, please correct any inaccurate fields so that we may
update our records.
Departure Date Section
This section is required to verify that your trip and medical emergency fell within the effective date of your
policy. If you have an annual policy plan, you must include proof of departure from your province of residence.
The type of proof depends on whether you traveled by airline or car. Any one of the documents listed below
are accepted as proof of departure:
- Airline tickets/boarding passes
- Travel Itinerary
- Original gas receipts
- Original hotel receipts
- Original meal receipts
- Toll highway receipts
SECTION B – OTHER EMERGENCY MEDICAL INSURANCE COVERAGE
This section allows us to coordinate medical payments with any other insurance plans that you may have in
addition to this plan. Complete Section B if you have other out of province travel insurance such as a group
policy through work or coverage through a credit card. If you do not have other insurance, indicate this by
selecting the option “I do not have any other out of province medical insurance coverage.”
SECTION C – MEDICAL INFORMATION
This section provides a brief synopsis of the medical situation incurred which allows us to verify the information
already on file when the case initiated.
If you were hurt, fill out the Injury section.
If you were sick, fill out the Sickness section.
SECTION D – CERTIFICATION & AUTHORIZATION
This section must be completed in order to release payment of your claim. Completion certifies that
the information provided in connection with this claim is complete, true and accurate.
This signed release allows us to access your personal medical information that is related to the claim. When
determined applicable, it also allows us to obtain your past medical history from your treating providers in
Canada in order to verify eligibility and stability requirements outlined in accordance to your policy.
PROVINCIAL HEALTH INSURANCE PLAN AUTHORIZATION FORM
This section allows us to submit to your Provincial Health Plan or other Insurance plans for eligible medical
expenses ACM pays on your behalf.
Residents of British Columbia must also complete the Schedule A enclosed with these forms.
Active Care Management | P.O. Box 1237 Station A Windsor, ON N9A 6P8 | Form 100 A 07 2015
REQUIRED ATTACHMENTS
To process your claim, the following documents should be sent with your forms (please do not staple
documents together);
 If you paid any expenses yourself, please provide proof of payment by sending original bills and
receipts. Please fill out the Expense Sheet attached. Please note, cash register receipts, credit card
receipts and/or debit slips alone are insufficient. FOR PRESCRIPTION DRUGS: Official pharmacy
receipts are required which must contain patient’s name, date of service, drug name, quantity
dispensed.
 All medical records, documents & certificates, provided at the time of treatment. This includes a
diagnosis report, list of medication given and type of treatment provided. For example: a copy of the
Emergency Room (ER) report, clinical documentation or a written letter from the doctor you saw.
 If you were hospitalized, we require a copy of your medical records from the treatment facility you
attended.
 If you have any additional information about your claim, please submit.
SUBMITTING YOUR CLAIM
 By Mail: All original forms, along with all documents noted above can be sent to our claims office:
Canadian Mailing Address
Active Care Management
P.O. Box 1237
Station A
Windsor, ON N9A 6P8
U.S.A. Mailing Address
Active Care Management
535 Griswold Ave.
Ste 111-605
Detroit, MI 48226
Please save copies of all original claim forms, receipts and supporting documentation. ACM reserves the
right to request original documentation when necessary to adjudicate your claim.
WHAT TO EXPECT DURING THE CLAIMS PROCESS
Once your completed claim package is received, your claim will go through the following stages:
1. Initial Review
Your documentation will be reviewed by our team for completeness and accuracy. This means we will be
checking to ensure all the required documentation mentioned above is included with your claim form. If
required documentation is missing, you will be notified by ACM. When all required documentation is received,
your claim will be assigned to a Claim Adjudicator who will begin the Evidence Review Stage.
Tip: Ensure that all sections of your claim form are fully completed, signed and dated. Submitting a complete
claims package will ensure your claim is expedited through the Initial Review stage.
2. Evidence Review
During this stage, the Claim Adjudicator will review the details of the claim and identify if a decision can be
made or if further clarification and collection of information is required. It is during this stage that past medical
history, treatment notes or additional supporting evidence may be obtained. When all evidence is obtained,
the claim will progress to the Decision Stage.
Tip: You will be notified within 30 days if additional evidence is required.
3. Decision Stage
Once at this stage, the Claim Adjudicator will review all information collected, assess the claim under the
insurance policy’s terms and conditions and make a decision. For approved claims, you will be notified of the
decision by receiving a cheque with an explanation of benefits. When a claim is denied, you will receive written
correspondence from ACM. Payments by cheque are issued within three business days of approval decision
and sent by standard Canadian mail.
Active Care Management | P.O. Box 1237 Station A Windsor, ON N9A 6P8 | Form 100 A 07 2015
EMERGENCY TRAVEL MEDICAL CLAIM FORM
Send your completed form to:
[CANADA] Active Care Management, P.O. Box 1237, Station A, Windsor, ON N9A 6P8
[U.S.A] Active Care Management, 535 Griswold Ave., Ste 111-605, Detroit, MI 48226
IMPORTANT: This claim form must be completed in full, signed, and returned to our office. The receipt of your completed forms will initiate the claims review
process. The Authorization section must be completed in order to process your claim. By signing and submitting this form you certify that the information
provided in connection with this claim is complete, true and accurate.
SECTION A – CLAIMANT INFORMATION
Claimant’s Name (Last Name, First Name, Middle Initial)
Date of Birth
Policy Number
Gender
MM | DD | YYYY
 Male
 Female
Home Address
City
Email Address
Travel Destination
Province
Postal Code
Phone
Fax
(
(
)
Departure Date
)
Return Date
MM | DD | YYYY
MM | DD | YYYY
SECTION B – OTHER EMERGENCY MEDICAL INSURANCE COVERAGE
Do You and/or Your Spouse or Child Have Other Emergency Medical Insurance Benefits? (Check all that apply)
 Employer  Retiree Plan  Home/Auto  Other  I do not have any other out of province medical insurance coverage.
Plan
Name of Insurance Company
Group Policy #
Member ID #
Phone #
Your Employer
Your Spouse’s
Employer
Name of Spouse (last name, first name):
Retiree Plan
Other Coverage
Signature of Policyholder of other coverage
Date of Birth
MM | DD | YYYY
Do you have credit card insurance coverage for out-of-Province travel?  No  Yes, If yes, provide:
Name of Issuing Bank for Credit Card:
Name of Cardholder
Credit Card #
Date of Expiry
MM | DD | YYYY
Signature of Cardholder (if different from insured)
Date Signed
MM | DD | YYYY
Does this claim relate to a Motor Vehicle Accident?  No  Yes
Name of Motor Vehicle Insurance Company
Policy #
Address
City
Phone
(
Province
)
Postal Code
ACM is committed to protecting the privacy, confidentiality and security of the personal information we collect, use and disclose. Your
personal information will be used only for the purpose of providing you with the requested insurance services. For a copy of ACM’s privacy
policy, please contact us.
Active Care Management | P.O. Box 1237 Station A Windsor Ontario N9A 6P8
EMERGENCY TRAVEL MEDICAL CLAIM FORM
SECTION C – MEDICAL INFORMATION – Please list the name and telephone number of your Family Physician as
well as any Specialists that you have been or are currently seen by.
Name of Usual Canadian Physician (Family Doctor)
Phone
(
Physician’s Name & Specialty
)
Phone
(
Physician’s Name & Specialty
)
Phone
(
Was this condition related to a Pregnancy?  No  Yes,
If Yes, Expected Date of Delivery
)
MM | DD | YYYY
Injury
Date of Injury
Is this claim the result of an Injury?  No  Yes
MM | DD | YYYY
Brief Description of Injury and Diagnosis
Sickness
Date Symptoms first appeared
MM | DD | YYYY
First date of Treatment
Diagnosis
MM | DD | YYYY
Treating Doctor’s Name
Phone
(
)
List names of any Medications you were taking prior to visiting the Doctor:
Date of Previous Occurrence
Have you ever experienced this sickness or a similar problem before?  No  Yes
MM | DD | YYYY
Date Diagnosed
Do you have any Chronic Sickness or Disease?  No  Yes
MM | DD | YYYY
Describe Conditions / Diagnosis:
SECTION D – CERTIFICATION & AUTHORIZATION – Signature required below.
The insurer, its agents and administrators are obliged to collect and retain certain personal and/or health information about you in connection with
your insurance coverage. They use and disclose that information only for the purposes of administering your policy/policies of insurance, providing
customer service and assessing and paying claims.
I/We authorize any licensed physician, medical practitioner, hospital, clinic, other medical facility or provider of health care, insurer or reinsurer,
provincial health insurance plan and employer(s) to provide Active Care Management (ACM), and its representatives employed to assist in the
administration of this claim, any information, including personal information, data or records t hat are in their possession/knowledge regarding my
medical history and treatment.
I/We direct and authorize my Government Health Insurance Plan (GHIP) to make payment in respect of my claim for out of country Health services
to ACM, directly and I hereby release GHIP, upon payment to ACM from any further claim or cause of action in connection herewith.
I hereby consent and authorize GHIP to directly or indirectly collect information contained in the claim and source documents pursuant to the
freedom of information and protection of privacy act, and the Health Insurance Act.
I/We authorize ACM to coordinate the payment of benefits with any other insurance carriers which may also have a liability for this claim. I/We
hereby irrevocably direct ACM to make any payments, receive payments and settle with other carriers on my/our behalf.
I hereby consent to the use of ACM, the insurers its agents and administrators of the personal and health information about me disclosed herein and
in all documents or information provided in connection with my policy/policies of insurance for purposes cited above.
A photocopy of this authorization shall be considered as effective and valid as the original. This authorization shall be considered valid for the
duration of the claim, but not to exceed one year from date signed.
I certify that the information provided in connection with this claim is complete, true and accurate.
Notice: The provincial legislation in some provinces requires us to inform you that the time limit for taking legal action is set out in the Insurance Act
or other legislation that applies to your claim.
Policyholder’s Signature (If minor, signature of parent or legal guardian)
Date
MM | DD | YYYY
Name of Patient/Insured (Last Name, First Name, Middle Initial)
Date
MM | DD | YYYY
If you authorize payment of this claim to anyone other than yourself or your provider, please
provide name of recipient:
Date
MM | DD | YYYY
Active Care Management | P.O. Box 1237 Station A Windsor Ontario N9A 6P8
Expense Sheet
Name of Insured:_____________________________________
Please list below any PAID out of pocket expenses. Please note, your claim will not be processed unless original
documentation is supplied. If you receive additional bills after submission of this expense sheet, contact our office for
additional instructions prior to making a payment.
Facility Name
(pharmacy,
doctor, etc.)
Comments
Description of
Expense
(prescription)
Date of
Service
(mm/dd/yy)
Amount Paid
by Insured
Type of
Currency
Date Paid
(mm/dd/yy)
Receipt attached
(if no, please explain in
comment section below)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
(please use back of page if required)
Active Care Management | P.O. Box 1237 Station A Windsor, ON N9A 6P8 | Form 100 A 07 2015