Printable Forms: FNIS Group Insurance Extended Health/Vision and Dental Claim Forms
If applicable, any expenses eligible for coverage through the Non-Insured Health Benefits Program must be put through First Canadian Health.
Standard Group Dental Claim Form
- Plan Member and member’s Dentist must complete this form and submit it to First Nations Insurance Services’ office for processing. Any orthodontic services require a treatment plan. For dental services over $300 the member’s dentist should provide a dental pre-authorization.
Extended Health Benefits Claim Form
- Plan Member must complete this form and submit it for processing along with original (paid in full) health expense and/or vision expense receipts to First Nations Insurance Services’ office.
Application for Emergency Out of Saskatchewan Hospital/Medical Expenses Claim Form
- Plan Member and member’s Physician and/or Specialist must complete this form and submit it to First Nations Insurance Services’ office for processing along with original receipts.
Blue Cross: Direct Deposit Authorization
- Plan Member must forward the completed and signed Authorization form and VOIDED cheque along with their claim and applicable original receipts to First Nations Insurance Services Ltd. office in order to take advantage of this option. When a claim is processed, their benefit payment will be deposited to the account provided through Electronic Funds Transfer. They need only forward the Authorization and Voided cheque the one time, unless there is a change to their banking information.
Back to Printable Forms Main | Back to FNIS Group Insurance Association Plan Forms
