![]() ![]() Accident or Injury Reimbursement Agreement (ICBC) - Health, dental or disability claim for a VEHICULAR accident or injury prior to Novem.Accidental Death Claim - Individual Plans - Use this package if a person insured under and Individual plan with an Accidental Death benefit passes away due to an accident.Accidental Loss & Dismemberment Claim - Individual Plans - Use this package if a person insured under and Individual plan with an Accidental Loss/ Dismemberment benefit suffers a loss specified in the policy.Note: Claims for vision care and paramedical treatments may also be submitted online through Member Profile. Individual Plan Health Claim Form - Use this form to submit claims for any health expenses covered under the provisions of your benefit plan. ![]() If you purchased a plan for Individuals and Families Blue Cross Life Insurance forms from Assumption Life.Prior Authorization for High Cost Drugs - Certain new high cost drugs require prior authorization before we can reimburse prescription costs.Custom Foot Orthotics claiming checklist - Complete this checklist and submit with your claim if you are claiming for custom foot orthotics.Custom Orthopedic shoe claiming checklist - Complete this checklist and submit with your claim if you are claiming for orthopedic shoes.Accident or Injury Reimbursement Agreement (WorkSafe) - Health, dental or disability claim for a WORKPLACE accident or injury.Accident or Injury Reimbursement Agreement (ICBC) - Health, dental or disability claim for a VEHICULAR accident or injury prior to November 9, 2018.Accident or Injury Reimbursement Agreement - Complete this form if your health, dental or disability claim is the result of an accident or injury not related to a workplace or automobile incident.Make sure to answer yes to the question “Apply unpaid balance to HSA plan?” Health Spending Accounts - Use the standard health claim form to submit claims under your HSA plan (if applicable) for expenses that are recognized as medical expenses under Canada Revenue Agency (CRA) Income Tax guidelines.Claims for Orthodontic treatments may also be submitted online through Member Profile. Dental Claim Form - Use this form to submit claims for dental expenses if your dentist is not able to submit your claim directly to Pacific Blue Cross.Health Claim Form - Use this form to submit claims for any health expenses covered under the provisions of your benefit plan.Member Forms For plan members with benefits through their workplace ![]()
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