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FORMS & DOCUMENTS

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



  • 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 Plan 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. Once you return from your travels, please complete a Travel Claim Form Request or call 1-800-667-4511 to have the proper travel claim form sent directly to you.

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: 2017-20182016-2017

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

 

Travel Brochure

Find the details of your 365 day travel coverage and a removable emergency travel card

 

Full benefit details can be found on the Blue Cross Portal

Opt-In Registration Form

Use this form if you with to enroll yourself and/or your family onto the ULSU Health & Dental plan. Completed forms can be taken to the ULSU Health Plan Office for processing.

Exception Request Form

 

This form is used for students requesting exceptions to the limitations of the drug plan.  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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