Application

Prism
Spectra®

Thank you for applying to the Prism Spectra program.

Thank you for applying to the Prism Spectra program. This program is geared towards healthy individuals who are taking very little or no medications. The medications you are taking will more than likely be excluded under these particular programs. If you are unsure if your medication(s) will be covered, please give us a call. This program is an underwritten program, which means your eligibility is based on your current medical condition and the prescription(s) you may be taking. Please make sure you fill out all information boxes and read and check all checkboxes in order to apply successfully.

We require your agreement with the terms of purchase.

Please read the terms carefully before you proceed and indicate your agreement by clicking the box below. If you do not agree with these terms, please exit the site.

I/we have read and agree with terms of purchase.

Providing marketing and administration for
Prism® Health and Dental Programs

Coverage provided by

Prism Spectra®   Section ACoverage InformationStep 1 of 9

By clicking on this checkbox I/we confirm that all individuals applying for coverage have Provincial Government Health Care.

I/We apply for:

I/We apply for the following Prism Spectra® Plan:

Total Monthly Rate:

YES. Please include Hospital Accommodation (Approval and additional premium required)

Are you covered, or were you covered under any other health plan?

If yes, please indicate if coverage was:

Did your coverage end?

When did your coverage end? (MM/DD/YYYY)

Name of insurance carrier:

ID#

Previous Employer's Name

Dependent Child

C

Prism Spectra®   Section BIndividuals to be CoveredStep 2 of 9

NOTE: Dependent children must be under age 21 to qualify for coverage.

 

Last Name

First Name

Middle Initial

 

Gender
M/F

Date of Birth

Age

Applicant

E

S

Dependent Child

C

Prism Spectra®   Section CMailing InformationStep 3 of 9

Last Name:

First Name:

Middle Initial:

Street Address 1

Apt. No:

Street Address 2

City/Town:

Prov.:

Postal Code:

Home Phone:

Business:

Cell:

Email:

If additional information is required, how may we contact you during our regular business hours?
(Monday to Friday, 8:45 am to 4:45 pm ET)

Family Status

Applicant’s Occupation:

Prism Spectra®   Section DGeneral Health InformationStep 4 of 9

Part - A
Have you, your spouse/partner or any listed dependent children EVER been treated for, consulted or received advice from a physician or specialist or had any indication/symptom of ANY of the following:

CheckYesorNofor all questions

A)  Depression, Anxiety, Sleep Disorder, Seizures, Alzheimer’s, Dementia, or any other Neurological or Mental Health/Emotional Disorders

B)  ADD (Attention Deficit Disorder), ADHD (Attention Deficit Hyperactivity Disorder), or ODD (Oppositional Defiant Disorder)

C)  Stomach/Bowel Disorder i.e. IBS/IBD (Irritable Bowel Syndrome/Disease), Colitis, Crohn’s, Ulcer, Hernia, Reflux, GERD (Gastroesophageal Reflux Disease) or Persistent Heartburn

D)  Menopause (including Peri), Infertility, Reproductive Disorder, PCOS (Policystic Ovary Syndrome)

E)  High Blood Pressure, Heart, Circulatory, Artery/Vascular Disease/Condition including PAD (Peripheral Artery Disease), PVD (Peripheral Vascular Disease), Angina, Stroke/Mini-Stroke or TIA (Transient Ischemic Attack)

F)  Elevated Cholesterol

G)  Alcoholism or Drug Dependency

H)  Skin Disorder (including Acne, Rosacea, Psoriasis and Eczema)

I)  AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS Related Complex), HIV (Human Immunodeficiency Virus), Liver Disorder (including Hepatitis), MS (Multiple Sclerosis) or other Immunological Disorders

J)  Osteo or Rheumatoid Arthritis, Back, Joint or Muscle Pain, Fibromyalgia, Gout, Bone Density Loss, Osteoporosis

K)  Asthma, Allergies, Lung or Respiratory Condition including COPD (Chronic Obstructive Pulmonary Disease), Bronchitis, Emphysema

L)  Headaches, Migraines

M)  Cancer, Tumour, Leukemia

N)  Cold Sores/Herpes, STD’s or STI’s (Sexually Transmitted Disease or Infection) or any other recurring infections

O)  Diabetes, Endocrine, Thyroid, Hormonal Disorder or Lupus

P)  Glaucoma

Q)  Prostate, Bladder (including Urinary Incontinence) or Kidney Disorder

R)  Any other Conditions, Diseases, Disorders, Injuries, Symptoms or have a referral/ test/ investigation/ results pending not listed above - please specify

Claims submitted are audited to verify accuracy of the medical information provided.

First name of person

Name of drug

Strength

Daily dosage

Length of time using the drug

Number of refills per year

Date of last refill

Approx. monthly cost

Prism Spectra®   Section EPrescription Drug InformationStep 5 of 9

Do you, your spouse/partner or any listed dependent children currently take or use any prescription drugs, including birth control, have a prescription for which refills are currently authorized or expect to be using any prescription drugs?

(Prescription drugs include, but are not limited to, samples, oral medication, injectables, creams, drops or serums.)

If you answered “YES” to this question, please provide details below:

First name of person

Name of drug

Strength

Daily dosage

Length of time using the drug

Number of refills per year

Date of last refill

Approx. monthly cost

Prism Spectra®   Section FStatement of HealthStep 6 of 9

1) Have you, your spouse/partner or any listed dependent children been hospitalized in the last two (2) years?


First name of person

Date of illness, injury or confinement

Number of days in hospital


Details of illness or injury


Diagnosis/Follow-ups

2) Do you, your spouse/partner or any listed dependent children expect to be hospitalized in the next six (6) months?


First name of person

Date of illness, injury or confinement

Number of days in hospital


Details of illness or injury


Diagnosis/Follow-ups

3) Are you, your spouse/partner or any listed dependent children pregnant?


First name of person


Due date of pregnancy

Number of days in hospital


Details of pregnancy


Diagnosis/Follow-ups

Name of Physician

Phone Number

Prism Spectra®   Section GMedical and Dental InformationStep 7 of 9

Do you have a family doctor?

Name of Physician

Phone Number

Have you, your spouse/partner and/or any listed dependent children had a medical exam within the last two (2) years?

If you answered “NO” please indicate date of last medical exam(s)

Do you, your spouse/partner and/or any listed dependent children plan to visit a dentist in the next three (3) months?

If “YES”, please indicate dental work to be done

NOTE: If the proposed dental work is expected to exceed $300 a detailed treatment plan is required from your dentist before your treatment begins.

Prism Spectra®   Section HPayment InformationStep 8 of 9

Payment for the first two (2) months of coverage is due on your coverage effective date. All future payments will be made thirty (30) days in advance of the month for which coverage is to be provided.

Is this a personal or business account?:

IMPORTANT: Applications cannot be processed without a “Void” cheque or a PAD form from your bank.
NOTE: We cannot accept line of credit or credit card cheques for pre-authorized payments.

Upload a VOID Cheque or PAPD Form

Transit Number

Branch Number

Account Number

Is this a joint account? If “YES” does this joint account require two (2) signatures

If two (2) signatures are required please provide information for both account holders

1st Account Holder Name:

Address 1:

Address 2:

City/Town:

Prov.:

Postal Code:

Phone Number:

2nd Account Holder Name:

Address 1:

Address 2:

City/Town:

Prov.:

Postal Code:

Phone Number:

Terms & Conditions

By clicking on the checkboxes below, I/we acknowledge that I/we have read and understand the terms and conditions.

 

I/We hereby authorize Green Shield Canada to withdraw the initial two (2) months’ premium from my/our Financial Services Account (Pre-Authorized Debit). Payment for the first two (2) months of coverage is due on the coverage effective date. Subsequent payments will be made thirty (30) days in advance of the month for which coverage is to be provided.

 

I/We hereby authorize Green Shield Canada to withdraw premium payments from my/our account specified on the attached void cheque or PAD form thirty (30) days in advance of the due date, on or about the first (1st) business day of each month. Should there be any change in either the amount or premium due date, Green Shield Canada will give the applicant written notice of at least thirty (30) days in advance of such change. Green Shield Canada may terminate coverage should a withdrawal be refused for any reason and the financial institution shall in no way be held liable should such an event occur.

This authorization shall remain valid unless written notice requesting cancellation by either the applicant or account holder is received by Green Shield Canada/ Special Benefits Insurance Services at the address shown below, ten (10) business days prior to the next pre-authorized debit due date.

Special Benefits Insurance Services, 366 Bay Street, 7th floor, Toronto, ON M5H 4B2

 

I/We understand that I/we may obtain a sample cancellation form or more information regarding my/our right to cancel this Pre-authorized Debit (PAD) Agreement at either my/our financial institution or by visiting cdnpay.ca.

 

I/We understand that I/we have certain recourse rights if any debit does not comply with this PAD Agreement, and that I/we may either obtain a form for reimbursement claim or more information regarding my/our recourse rights by contacting my/our financial institution or by visiting cdnpay.ca.

 

I/We understand that by checking this box the name(s) entered below constitute a legal and binding signature(s) confirming that I/We acknowledge and agree to the above terms for the purposes of applying.

Name of Account Holder (required)

Date

Name of Second Account Holder
(if applicable)

Date

Prism Spectra®   Section IDeclarations and AuthorizationsStep 9 of 9

NOTE: The information provided on this form is confidential.

Terms & Conditions

By clicking on the checkboxes below, I/we acknowledge that I/we have read and understand the terms and conditions.

 

I/We agree that the statements contained herein are true and complete, to the best of my/our knowledge and form the basis for any coverage approved. I am authorized to release information concerning my spouse/partner and my dependent children, for the purposes of determining their eligibility for benefits.

 

I/We understand that failure to disclose or falsifying information regarding my health and/or that of my spouse/partner and/or dependent children could result in denial of a claim and the cancellation or modification of this coverage.

 

I/We understand that it is my/our obligation to inform Special Benefits Insurance Services Agency Inc. of a change in my health and that of my spouse/partner and any listed dependent children due to either injury or illness which occurs after the date of application and prior to the effective date of the policy.

 

I/We understand that the coverage shall not become effective until the first (1st) of the month following approval by Green Shield Canada. I/We authorize any physician, dentist, medical practitioner, hospital, clinic or other medical or medical related facility, insurance company, or other organization, institution or person that has any records or knowledge of my health, and that of my spouse/partner and any listed dependent children, to exchange any such information as is needed to administer benefit claims and/or to confirm the accuracy of the information with Green Shield Canada. A reproduction of this consent and authorization shall be as valid as the original.

 

I/We acknowledge that Special Benefits Insurance Services is the distributor for this program and receives a commission from GSC. If you have any questions about this program or our compensation, please call us at 1-800-667-0429. By no means does this commission influence which plans we offer. Each offering is unique and is based on the individuals needs and budget.

 

I/We understand that by checking this box the name(s) entered below constitute a legal and binding signature(s) confirming that I/We acknowledge and agree to the above terms for the purposes of applying.

Name of Applicant

Date

Name of Spouse/Partner

Date

Coverage Provided by Green Shield Canada

Green Shield Canada’s commitment to privacy. Your personal information is collected for the purpose of providing you with health and dental benefits, claims analysis and payments. For information on Green Shield Canada’s privacy policies and procedures, visit greenshield.ca

ADDITIONAL INFORMATION FORM