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MediDirect The Health and Dental Benefit Plan The health and dental coverage you want
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Claim Forms




Employer and Employee Forms

ALL FORMS CAN BE FILLED IN ON-LINE, THEN PRINTED OUT FOR MAILING

USERS OF ADOBE READER VERSION 7 AND LATER CAN SAVE DATA TYPED INTO THESE FORMS. CLICK THE ICON BELOW TO DOWNLOAD THE LATEST VERSION OF ADOBE READER.

Get the latest version of Adobe Reader

GENERAL CLAIM FORM
For Most Companies

CLICK HERE TO VIEW A SAMPLE CLAIM       
ONTARIO EMPLOYERS ONLY: CLICK HERE TO VIEW A SAMPLE CLAIM

PREFUNDED CLAIM FORM 
Companies with special arrangements

CLICK HERE TO VIEW A  SAMPLE CLAIM

IF YOU ARE UNSURE WHICH CLAIM FORM TO USE, PLEASE CALL US
Toll Free 1-866-234-5162 or in Calgary at (403) 537-6298
 

Employer Forms

Add or Delete Employee(s)     
  • Related Form: New employees must complete an  "Employee Personal Information and Authorization" form

Change Employee Benefit Levels                                 
Company-Wide or for Individual Employees
Change your Health Spending Account Levels for any or all classifications of employees, or change a classification for an individual employee         

  • Related Form: Changes in marital or dependent status             
    that affect an employee’s benefit level require inclusion
    of "Employee Change Personal Information" form


Employee Forms

Employee Personal Information and Authorization
For new employees who are eligible to participate in the program             

Change Employee Personal Information and Authorization 
For existing employees who wish to change their name, contact information,
marital status, or dependent information
  • Related Form: Changes in marital or dependent status                             
    that affect your benefit level require inclusion of
    "Employer Change Employee Benefit Level and Classification" form 
 

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