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FORMS & DOCUMENTS

Please find below some useful forms & documents related to your Health & Dental Benefits.



  • Claim Forms
  • Info Brochures
  • Registration Forms
  • Other Plan Forms

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, use this form.

Health & Dental Plan Brochure   2021-2022  |  2020-2021

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

Travel Brochure

Find the details of your 365 day travel coverage here.


Full benefit details can be found on the Blue Cross Portal

Opt-In Registration Form

Use this form to enroll yourself and/or your family onto the ULSU Health & Dental benefits for the 2021-22 Year. Completed forms can be emailed to the ULSU Health Plan Office for processing.

Special Authorization Request Form

This form is used for students requesting special authorization for a specific drug to be covered under the 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 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 traveling to Cuba do
NOT require a travel letter, your provincial health coverage is sufficient for entering the country.

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