GREEN SHIELD CANADA CLAIM SUBMISSION INSTRUCTIONS Please call our Customer Service Centre at 1-844-997-9888 if you require any assistance in completing this form. ion that requires prior authorization needs to complete a form are the responsibility of the plan member. Mail: Express Scripts Canada Clinical Services 5770 Hurontario Street, 10th Floor, Mississauga, ON L5R 3G5 t a guarantee of approval. Box 1606, Windsor ON N9A 6W1 Forms can be faxed or emailed: Fax: 1-519-739-6483 or Toll Free: 1-866-797-6483 or Email: drugspecial.autho@greenshield.ca The pharmacy can then print the appropriate form(s) that corresponds to the special authorization drug. And, although GSC does not typically approve requests for an off-label use, we feel it’s important to have some flexibility to accommodate unique situations. Children under the age of five: Please note that orthotic claims for children under the age of … Special authorization requests that specifically request approval for a drug being prescribed off label are relatively rare. Once the plan member’s special authorization request is approved, a HealthForward case coordinator will call the plan member to introduce them to the specialty drug PPN program and identify approved network pharmacies in their community. The pharmacy will receive a message indicating that the drug must be authorized. Get prior authorization. the phone numbers listed on the back of this brochure. Our 1.5 hour sessions can be booked for couples upon special request at the rate of $225 plus HST. ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST Read our brochure (PDF, 761 KB) Opens in a new window. The Exceptional Access Program (EAP) facilitates patient access to drugs not funded on the Ontario Drug Benefit (ODB) Formulary, or where no listed alternative is available.In order to receive coverage, the patient must be eligible to receive benefits under the Ontario Drug Benefit (ODB) program. Information contained in this form is Protected Health Information under HIPAA. Email: medical.authorization@greenshield.ca To the Patient: The details requested below are mandatory in order for Green Shield to determine our liability with respect to this request. Ensure criteria are met or that the drug prescribed is not a Special Authorization drug before filling your prescription at … endstream endobj 11 0 obj <> endobj 12 0 obj <> endobj 13 0 obj <>stream ... Green Shield Canada and SSQ Financial. This form must be given to the plan member to be completed by their physician and returned to Green Shield Canada for assessment. Complete Green Shield Special Authorization 2020 online with US Legal Forms. 10009 108 Street NW, Edmonton, Alberta T5J 3C5. The forms in this section of the website are for download and print only. Box 1606, Windsor ON NSA 6W1 Dosage: Forms can be faxed or emailed: Fax: 1419-739-6483 or Toll Free: 1-866-797-6483 or Email: druqspecial.autho@qreenshield.ca For general information about Special Authority requests, including standard turnaround times, see Submitting a Special Authority Request—Information for Prescribers. Extended Release Opioid Prior Authorization Form; Medicare Part D Hospice Prior Authorization Information; Modafinil and Armodafinil PA Form; PCSK9 Inhibitor Prior Authorization Form; Request for Non-Formulary Drug Coverage; Short-Acting Opioid Prior Authorization Form; Specialty Drug Request Form; Testosterone Product Prior Authorization Form Green Shield Vision Claim Form (eye test & glasses) Green Shield Dental Claim Form. Then, in the list below, select the form for the drug you have been prescribed and follow the instructions. Authorization. Once completed, please return request along with any original paid “Official Pharmacy” receipts to: Green Shield Canada Drug Special Authorization Department P.O. If PharmaCare approves this Special Authority request, approval is granted solely for the purpose of covering prescription costs. Payment is due on the day of session and can be made by cheque or e-transfer. SPECIAL AUTHORIZATION REQUEST Standard Form Fax Requests to 905-949-3029 OR Mail Requests to Clinical Services, ClaimSecure Inc., Suite 620, 1 City Centre Drive, Mississauga, Ontario, L5B 1M2 OR Email Special.Authorization@Claimsecure.com INCOMPLETE FORM MAY RESULT IN DELAYS OR A DENIAL SP-A1 (2016/03) TO BE COMPLETED BY PATIENT Box 1606, Windsor ON N9A 6W1 Forms can be faxed or emailed: Fax: 1-519-739-6483 or Toll Free: 1-866-797-6483 or Email: drugspecial.autho@greenshield.ca Green Shield Canada Drug Special Authorization Deparbnent P.O. A Drug Special Authorization form is required when a pharmacy receives a denial for an electronic drug claim that requires prior authorization. Box 1606, Windsor ON N9A 6W1 . The pharmacy can then print the appropriate form(s) that corresponds to the special authorization drug. 3. Green Shield General Claim Submission Form. Once completed, return request form along with any original paid “Official Pharmacy” receipts to: Green Shield Canada, Drug Special Authorization Department, P.O. ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST hޤ�[��:���AGŗĎ+�J�B��T$�UB���Q.U���4i{v� ��xfl��_\MS�u@'��'@�G$. A response letter outlining our liability will be forwarded to the patient promptly. Sessions generally last 50 minutes and range from $150-195 per session, plus HST. SPECIAL AUTHORIZATION REQUEST Centre Drive, Mississau a, Ontario, 1.5B IM2 Certificate Number OR Mail R uests to Clinical Services, ClaimSecure Inc., Suite 620, I Ci Plan Member Patient Name City Group Number Relationship to Member aself aspouse Street Address Telephone Number Patient Date of Birth (YYYY/MM/DD) Province Postal Code 27 0 obj <>/Filter/FlateDecode/ID[<8E1630CD77DD9F29367752675B33DF9E>]/Index[10 33]/Info 9 0 R/Length 85/Prev 35230/Root 11 0 R/Size 43/Type/XRef/W[1 2 1]>>stream Our prior authorization program is fundamental to a robust drug plan management strategy. Green Shield Canada 5140 Yonge St, Suite 2100 Toronto, ON M2N 6L7 Fax: 416.733.1955 Email: ombudsman@greenshield.ca. Green Shield Canada Prescription Drug Special Authorization Request Form (General) Green Shield Canada Erectile Dysfunction Special Authorization Request Form (Rev 2012-01) Medavie Blue Cross – Attending Physicians Statement (General) (FORM-401E) Combined Insurance – Attending Physicians Statement (294590)(09/2016) 00, 01, etc.) Special Authorization form in your patient file at your doctor’s office. important for the review (e.g., chart notes or lab data, to support the authorization request). 2. Green Shield Audio Claim Form. This form must be given to the plan member to be completed by their physician and returned to MÉDIC Construction (CCQ) for assessment. if a drug-specific form is not available. Once completed, return request form along with any original paid “Official Pharmacy” receipts to: Green Shield Canada, Drug Special Authorization Department, P.O. 10009 108 Street NW, Edmonton, Alberta T5J 3C5. For prior approval, please forward this form to the address indicated. Mail: Express Scripts Canada Clinical Services 5770 Hurontario Street, 10th Floor, Mississauga, ON L5R 3G5 t a guarantee of approval. being requested, or use the . PharmaCare approval does not indicate that the requested medication is, or is not, suitable for any specific patient or condition. Green Shield Canada, Drug Special Authorization Department, P.O. Your request be reviewed and evaluated by our Drug Request a form by calling Alberta Blue Cross Customer Services using . Sign the form. Plan members will receive re drug benefit plan only if the request … Sessions generally last 50 minutes and range from $120 per session. Green Shield Canada (GSC) has always required prior authorization for drugs covered by British Columbia’s Special Authority program, and Saskatchewan’s and Manitoba’s Exceptional Drug Status (EDS) programs. Fill out, securely sign, print or email your green shield claim form for medical devices instantly with SignNow. Once completed, please return request to: Green Shield Canada Drug Special Authorization Deparbnent P.O. The forms in this section of the website are for download and print only. Available for PC, iOS and Android. Start a free trial now to save yourself time and money! If you require an accessible communication format or support to use this site, or if you have any feedback on how we can make this site more accessible for persons with disabilities, please click here or contact customer.service@greenshield.ca. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. For detailed instructions on completing the form, see the Prescriber Checklist (PDF, 158KB). h�bbd``b`j~@�q3�`a� "H0�� �D� ٙ@�+d� ��D���@���o}0 �", Request for special authorization will be considered for : - the treatment of children with central precocious puberty. If you would like to initiate a search for unclaimed property, please complete this GSC Unclaimed Property Request Form and … The pharmacy can then print the appropriate form (s) that corresponds to the special authorization drug. GREEN SHIELD Dear Plan Member: ERECTILE DYSFUNCTION SPECIAL AUTHORIZATION REQUEST FORM Please have the following Prescription Drug Special Authorization form completed in full by your physician. Maple allows you to instantly connect with a Canadian-licensed doctor for medical care from your phone, tablet, or computer – any time, 24/7/365. Green Shield General Claim Submission Form. No more waiting rooms. Consult the Special Authorization list when your doctor prescribes a new medication to determine eligibility. %%EOF 00, 01, etc.) you are eligible to; coverage by another plan (public or private) please have doctor indiæte below. Plan members will receive re drug benefit plan only if the request … GREEN SHIELD CANADA CLAIM SUBMISSION INSTRUCTIONS Please call our Customer Service Centre at 1-888-711-1119 if you require any assistance in completing this form. regarding the above-named patient, for the purpose of assessing this prior authorization request and any related claim and administering the benefit plan under which any such claim is made, and (b) to contact, and to obtain any such personal information from and to disclose any such Box 1606, Windsor ON NSA 6W1 Dosage: Forms can be faxed or emailed: Fax: 1419-739-6483 or Toll Free: 1-866-797-6483 or Email: druqspecial.autho@qreenshield.ca Coverage is contingent on your continued status as a Green Shield Canada cardholder or beneficiary. Green Shield Prescription Drug Special Authorization Request Form This form must be given to the plan member to be completed by their physician and returned to Green Shield Canada for assessment. to learn how to get prior authorization. Special Authorization Forms for Hydroxychloroquine No Longer Required by Green Shield Canada Jun 23, 2020 We have spoken directly with Green Shield Canada, and we are pleased to confirm that special authorization forms are no longer required when prescribing HCQ. h�b``�g``2e ��E���Y8������a3�Ƀ;Lk�ߨ1Lq�漢��wе����7�|���6��A�g� 0 ?�� We have specialists including physicians, pharmacists and nurses who have the expertise to make decisions about the drugs that should be included in our prior authorization program. or 2. Easily fill out PDF blank, edit, and sign them. Green Shield Canada is committed to inclusivity and providing accessible information and communications. Drug Special Authorization Request Form. Extended Release Opioid Prior Authorization Form; Medicare Part D Hospice Prior Authorization Information; Modafinil and Armodafinil PA Form; PCSK9 Inhibitor Prior Authorization Form; Request for Non-Formulary Drug Coverage; Short-Acting Opioid Prior Authorization Form; Specialty Drug Request Form; Testosterone Product Prior Authorization Form If you experience any challenges, please contact admin@ontariorheum.ca Special Authorization Forms for Hydroxychloroquine No Longer Required by Green Shield Canada Jun 23, 2020 We have spoken directly with Green Shield Canada, and we are pleased to confirm that special authorization forms are no longer required when prescribing HCQ. Forms can be faxed or emailed: Fax: 1-519-739-6483 or Toll Free: 1-866-797-6483 or Email: drugspecial.autho@greenshield.ca Box 1606, Windsor ON N9A 6W1 Forms can be faxed or emailed: Fax: 1-519-739-6483 or Toll Free: 1-866-797-6483 or Email: drugspecial.autho@greenshield.ca ion that requires prior authorization needs to complete a form are the responsibility of the plan member. Special . A Drug Special Authorization form is required when a pharmacy receives a denial for an electronic drug claim that requires prior authorization. AUTHORIZATION FORM FOR PROSTHETIC APPLIANCES AND DURABLE MEDICAL EQUIPMENT PO Box 1623, Windsor, Ontario N9A 7B3 Attn: EHS Department Customer Service Centre 1-888-711-1119 or (519) 739-1133 Fax (519) 739-0046 Email: medical.authorization@greenshield.ca process take? Prior Authorization. to 1 … %PDF-1.4 %���� 0 Fax toll-free in B.C. Green Shield Audio Claim Form. The pharmacy will receive a message indicating that the drug must be authorized. providerConnect is committed to inclusivity and providing accessible information and communications. Green Shield Canada Prescription Drug Special Authorization Request Form (General) Green Shield Canada Erectile Dysfunction Special Authorization Request Form (Rev 2012-01) Medavie Blue Cross – Attending Physicians Statement (General) (FORM-401E) Combined Insurance – Attending Physicians Statement (294590)(09/2016) SPECIAL AUTHORIZATION REQUEST Centre Drive, Mississau a, Ontario, 1.5B IM2 Certificate Number OR Mail R uests to Clinical Services, ClaimSecure Inc., Suite 620, I Ci Plan Member Patient Name City Group Number Relationship to Member aself aspouse Street Address Telephone Number Patient Date of Birth (YYYY/MM/DD) Province Postal Code Effective October 1, 2020, a new and improved process will make the prior authorization process for most of these drugs Patient support program Green Shield Prescription Drug Special Authorization Request Form PRESCRIBER’S SIGNATURE DATE Please forward this request to Alberta Blue Cross, Clinical Drug Services. If you require an accessible communication format or support to use this site, or if you have any feedback on how we can make this site more accessible for persons with disabilities, please. Printable Green Shield Medical Devices Claim Form. Green Shield Vision Claim Form (eye test & glasses) Green Shield Dental Claim Form. 10 0 obj <> endobj Save or instantly send your ready documents. HealthForward will also offer the plan member the opportunity to participate in adherence support services. Please ensure that you always provide your Green Shield Canada ID Number in full, including suffix (ie. PRESCRIBER’S SIGNATURE DATE Please forward this request to Alberta Blue Cross, Clinical Drug Services. 42 0 obj <>stream - patients with advanced (stage D2) symptomatic carcinoma of the prostate in patients who find surgical orchiectomy unacceptable - treatment of patients with endometriosis, including pain relief and the reduction of endometriosis lesions. Please ensure that you always provide your Green Shield Canada ID Number in full, including suffix (ie. How long does the . 1.5 hour sessions can be booked for couples upon special request at the rate of $150. Forms … Drugs and Devices Division Exceptional Access Program. Green Shield Canada 5140 Yonge St, Suite 2100 Toronto, ON M2N 6L7 Fax: 416.733.1955 Email: ombudsman@greenshield.ca. SPECIAL AUTHORIZATION REQUEST For Erectile Dysfunction Fax Requests to 905-949-3029 OR Mail Requests to Clinical Services, ClaimSecure Inc., Suite 620, 1 City Centre Drive, Mississauga, Ontario, L5B 1M2 OR Email Special.Authorization@Claimsecure.com INCOMPLETE FORM MAY RESULT IN DELAYS OR A DENIAL SP-A1 (2016/03) TO BE COMPLETED BY PATIENT FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll free all other areas. Please select the request form for the drug . FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll free all other areas. Special discounts, e.g., “two for the price of one” deals or “free items with the purchase of an orthotic.” Legitimate orthotic providers are not permitted to make such offers according to their code of ethics. Payment is due on the day of session and can be made by cheque or e-transfer. endstream endobj startxref When applying through the EAP, authorized prescribers (i.e., physicians or nurse practitioners) can use the Standard Form [Request for an Unlisted Drug Product – Exceptional Access Program (EAP)], or for certain drugs, authorized prescribers can use a drug specific electronic form (e-form). SPECIAL AUTHORIZATION REQUEST Standard Form Fax Requests to 905-949-3029 OR Mail Requests to Clinical Services, ClaimSecure Inc., Suite 620, 1 City Centre Drive, Mississauga, Ontario, L5B 1M2 OR Email Special.Authorization@Claimsecure.com INCOMPLETE FORM MAY RESULT IN DELAYS OR A DENIAL SP-A1 (2016/03) TO BE COMPLETED BY PATIENT If you require an accessible format, please.