Shouldice Hospital

INSURANCE INFORMATION CLAIM

Would you please complete the following insurance information and return it with your Medical Information Questionnaire.

All information will be treated as confidential.

(Please answer all questions)

Name: ________________________________________________

Health Card #: _______________________________________

Version Code: ________________________________________

Do you have semi-private coverage?: ____ Yes   ____ No

Name of Insurance Carrier: ___________________________

Group No: ____________________________________________

Certificate No: ______________________________________

Is this Insurance under YOUR name?: ____ Yes   ____ No

If 'No' name of Policy Holder?

Surname: ______________________ Given name: ___________________

Relationship to you? ____ Spouse   ____ Parent   ____ Other

Name of employer through whom premiums are paid:

________________________________________________

Is this a Worker's Compensation case? ____ Yes   ____ No

Claim #: _______________________________________________

Accident Date: _________________________________________

Employer's Name & Address (at time of accident)

___________________________________________________

___________________________________________________

___________________________________________________

S.I.N: ____________________________________________

Attending Doctor's Name: __________________________



Note to Patient: Any forms or Return to Work letters to be completed by our surgeons, should be
submitted to the accounting department on admission.