School Logo Image
Forms & Documents

Please find below some useful forms & documents related to your Health & Dental, and International Student Health Plan. 



  • Claim Forms
  • Info Brochures
  • Registration Forms
  • Other Plan Forms
Health and Dental Benefits Plan

For instructions on how to Make a Claim, please go HERE.
 

Health Claim Form   ENGLISH   |   FRENCH

Use this form to claim for Drug, Extended Heath & Vision claims.

 
Dental Claim Form    ENGLISH  |   FRENCH

Take this form to your dentist for completion before submission.  Note that we recommend students show their dentist their Health Benefits Card and have the dental office submit their claim electronically, or request a "Standard Dental Claim Form" in lieu of using this form.


Travel Claim Form

Claim forms change depending on your province of residence. For medical claims abroad (doctor visits, hospital visits, x-rays, lab work, etc.) please complete a Travel Claim Form Request and the proper claim form will be emailed to you.

For trip cancellation or interruption please complete this form. The attending physician form found here must also be completed if your trip cancellation or interruption is due to medical reasons.

For baggage claims, please complete this form.
 

Accident Claim Form

If you have been involved in an accident and need to claim under the Accident Policy of your coverage, please email info@studentvip.ca

International Student Medical Plan
Click here to make a claim


Once you have filled out the form above please mail or fax to:

Cowan Insurance Group
700-1420 Blair Towers Place, Ottawa ON K1J 9l8
Tel.: 1-888-509-7797 | Fax: 613-741-7771


*All claims must be reported to Cowan within 90 days of
occurrence.

* You are responsible for all fees charged for any supporting
documentation.

* Failure to complete and sign this form in its entirety or submit
supporting documentation will delay claim processing.

 
TIPS
  • Ensure you complete as much of the form as you can to avoid delays in processing. You must include your name, student ID number and contact information.

  • Include the invoice or receipt from your medical appointment with your claim form.

  • Include any medical notes, doctor notes, lab results or prescriptions to support your claim.

  • If mailing your claim, please keep copies of all of your documents.

Health and Dental Benefits

Health & Dental Benefits Brochure    2024-2025 |  2023-2024

Find all the details for your Health & Dental Benefits listed in this document.
 

Translated Benefits Postcards   Mandarin | Arabic 

A condensed document with your plan design and important contact information, fully-translated into different languages.


Travel Brochure

Find the details of your 365-day travel coverage here.

 

Full benefit details can be found on the Blue Cross Portal

International Medical Plan
International Health Plan Brochure 2024-2025 | 2023-2024 

Translated Brochures English |  Arabic |  Tagalog 
 
International Health Plan Policy English
 

Policy Summaries English |  Punjabi | Hindi Tagalog Spanish

ACSA Health & Dental Benefits Opt-In Form

Students who have been charged the Health & Dental benefits fee with their tuition may opt-in family members during the designated Opt-In Period.

In addition, students who have NOT automatically been charged the fee on their tuition may complete the Online Opt-In and submit it online to enrol on the Health & Dental Benefits.


ACSA International Student Health Plan Opt-Out Form 

Students who acquire Manitoba Health Coverage and would like to opt-out of the International Student Health Plan should click here to access the opt-in application form. Please submit your completed form and a copy of your Manitoba Health card to accsa@assiniboine.net 

ACSA International Student Health Plan Opt-In Form

Students Looking to opt-in their eligible family members to their International Student Health Plan should click here to access the opt-in application form. 

Manitoba Pharmacare Form

Pharmacare is a universal drug benefit program for eligible Manitobans, regardless of disease or age. Your Manitoba Pharmacare coverage is based on both your total family income and the amount you pay for eligible prescription drugs. Download this form to find out how to sign up.

Special Authorization Request Form

This form is used for student requesting special authorization for a specific drug to be covered under their benefits. For students requesting a CNS Cap Removal, or Monitored Medication Request, please contact Student VIP directly. Note that submission of this form does not guarantee your request will be granted.

Submit exception requests by sending as an "e-Claim" on the Blue Cross Member™ Portal, or by mailing it to Medavie Blue Cross™ at:

Medavie Blue Cross™
644 Main St.
PO Box 220 
Moncton NB
E1C  8L3

or by fax to 1-844-661-2640.

Visa/Coverage Letter Request

This form is used for students requesting proof of coverage for either a travel visa, applications for government programs or proof for other reasons.

Note that students travelling to Cuba do
NOT require a travel letter, your provincial health coverage is sufficient for entering the country.
live chat