Sending A Form or Document

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Use the drop down below to select who is to receive an attachment.

Send Form or Document to:

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-- Select -- Green Shield Canada MÉDIC Construction (Green Shield Canada) RBC Insurance SSQ Insurance providerConnect (Provider related information)

Form or Document:

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Provider Number:

Enter your assigned provider number.

Provider Name:

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Enter the providers name

Telephone Number: Area Code Prefix Line number ext.

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() -ext.

Email Address:

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Claim Form ID:

Claim form ID can be found on the explanation of benefit statement.

Plan Member ID:

Please enter the plan member ID

Patient Last Name:

Enter the patients last name

Patient First Name:

Enter the patients first name

Attach form or document Choose File Choose File Choose File *

(Overall maximum per submission is 24 MB):

Attach a document by clicking the browse button and following the instructions. Acceptable file types (extensions) are: bmp, doc, docx, gif, jpeg, jpg, pdf, png, tga, tif, tiff, txt, xls and xlsx.

By submitting this form or document, I acknowledge I have written authorization to submit personal information to the Carrier/Adjudicator/Third Party Payor, and for the Carrier/Adjudicator/Third Party Payor to exchange information with other parties as required and only when the information is needed to administer and/or to confirm the accuracy of the information in the form or document.
I agree the information provided is complete and accurate, to the best of my knowledge.