Claim Forms

Medical and Drug Expenses Claim Medical and Drug Expenses Claim
For Prescription Drugs, Vision Care, Medical Appliances, Paramedical Services, etc.

Use this form to claim Prescription Drugs, Vision Care, Paramedical Services like Physiotherapy or Chiropractic, Medical Appliances like Orthotics or a Blood Pressure Monitor, and other Medical expenses. Submit the completed form by mail with original receipts, or send by fax or email (click here for email submission details). You can include expenses for more than one person on the same form.

Dental Claim Dental Claim
Use this form if your dental office does not provide its own form.

Your dental office may provide a detailed dental claim form printed directly from their system, which you can submit instead of completing this form. Many dental offices will also submit electronically, in which case you do not need to submit a form at all. Use this form if your dental office asks you for a claim form from your benefits provider. A separate form should be submitted for each person’s dental expenses.

Short Term Disability Claim Ontario Short Term Disability Claim
Submit the fully completed form as soon as possible after you stop working.

Submit the Accident & Sickness Claim Form as soon as possible after an illness or injury, so that your claim can be evaluated. Check that your doctor has fully completed their section to avoid any delays. During the course of your claim, a Supplemental Disability Report may be required periodically.

Administrative Forms

Direct Deposit Authorization Form Direct Deposit Authorization Form
Submit this form with a void cheque.

To set up direct deposit of claims payments into your bank account, submit this form with a void cheque to The Benefits Trust.  An Explanation of Benefits will still be mailed to the home address we have on file for each employee, for their records.

Health Benefits Ontario Change of Record
Use this form to make changes to your coverage or information.

Do you need to add or remove a dependent? Change your coverage to Single, Family, or Waived? Advise us of your new address when you move? Change your beneficiary? All of these kinds of changes can be made with this form.

Ontario Health Benefits Plan Over-Age Dependent Form
Submit this form every school year for over-age dependents still in school.

This form must be filled out and submitted every school year to confirm that an over-age dependent is attending school full time, to be eligible for benefits coverage. This form should also be submitted for an over-age, disabled dependent whose disability began prior to reaching the maximum age for eligible dependents. Check your benefits booklet or ask your plan administrator for the definition of eligible over-age dependent.

Health Benefits Toronto Declaration Appointing Trustee Form
Submit this form for a life insurance beneficiary under age 18.

If you have Life Insurance coverage under your plan, you must appoint a beneficiary (the person or organization that would receive the life insurance settlement). If you appoint a beneficiary who is under age 18, you must appoint a Trustee by filling out and submitting this form.

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