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Manulife Affinity Markets Extended Health Care Claim Form

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Affinity Markets Extended Health Care Claim

The Manufacturers Life Insurance Company   |   Page 1 of 2   |   AF1039E (01/2011)

To be completed by the plan member unless otherwise indicated. Original receipts must be attached for all expenses. (Please attach to the back of this form.) Please retain copies for your files as original receipts will not be returned. Please complete page 2.

1 Plan member information










Are these expenses eligible for coverage under any type of workers' compensation board?

Are you, your spouse or dependants covered under any other plan for the expenses being claimed?

If "Yes," please retain photocopies of all receipts submitted with this claim for submission to your secondary carrier. If this is your first claim, or if information has changed, please provide the following:





2 Patient information

Complete for all expenses. Use one line per patient.

Patient's name Date of birth Relationship to plan member School and city If employed, hrs worked per week

3 Prescription drug expenses

Attach your prescription drug receipts to the back of this form. All receipts must contain the drug identification number (D.I.N.), the name of the prescription drug, strength and quantity. You are not required to list this information on the form.

4 Practitioner's/Paramedical expenses

(e.g. chiropractor, massage therapist, physiotherapist, etc.)

For practitioner/paramedical expenses please attach an itemized statement and/or receipt stating:

  • patient name,
  • name of practitioner,
  • type of practitioner,
  • date of service,
  • length of visit,
  • charge for treatment,
  • date last paid by provincial plan (if applicable) and
  • licence and/or registration number.

If for psychotherapy, please indicate type (individual, family, group, marriage) on your receipt.

Please complete page 2.

The Manufacturers Life Insurance Company   |   Page 2 of 2   |   AF1039E (01/2011)

5 Equipment and appliance expenses

For equipment and appliance expenses Manulife Financial requires a written recommendation from the prescribing physician, including diagnosis, and a copy of the provincial plan statement of payment (if applicable).



Has rental equipment been returned?

6 Vision care expenses

To be completed by supplier. Please enclose an itemized receipt indicating:

  • patient's name,
  • cost of contact lenses,
  • cost of glasses,
  • dispensing fee,
  • cost of eye exam,
  • date of eye exam,
  • cost of tinting,
  • treatment and
  • date dispensed.

Telephone: 1-800-268-3763

I certify that all goods or services being claimed have been received by me/my dependants.

7 Claims confirmation

NOTE - ORIGINAL RECEIPTS must be attached for all expenses.

$

I certify that all goods or services being claimed have been received by me/my dependants.

At Manulife Financial, we know that confidentiality of personal information is important. Any information you provide to us will be kept in an Affinity Markets Life and Health Benefits file. Access to your information will be limited to:

  • our employees and service representatives in the performance of their jobs;
  • persons to whom you have granted access; and
  • persons authorized by law.

You have the right to request access to the personal information in your file and, if necessary, correct any inaccurate information.

8 Mailing instructions

Please mail your completed claim form and receipts to the following address.

Manulife Financial Affinity Markets

Health Claims

PO BOX 4214, STATION A

TORONTO ON M5W 5M4

Telephone: 1-800-268-3763

Manulife Financial will not assume responsibility for any fees associated with the completion of this form.

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What the Manulife Affinity Markets Extended Health Care Claim Form Is

The Manulife Affinity Markets Extended Health Care Claim Form is the document policyholders use to request reimbursement for eligible extended health expenses under their Manulife Affinity Markets plan. It collects claimant and patient identity, plan and provider details, treatment dates, itemized costs and original receipts, and a declaration or authorization for benefits payment and information release. The form supports paper submission and electronic submission workflows; when signed electronically it must meet U.S. e-signature legal requirements such as ESIGN and applicable state e-signature statutes to be admissible. Accuracy and complete attachments speed adjudication and reduce the likelihood of denial.

Why a Complete, Compliant Claim Form Matters

A complete, accurate claim form documents entitlement, protects PHI, and helps avoid delays or denials. Proper formatting and required attachments let adjudicators validate expenses more quickly, while using compliant e-signature-capable platforms like signNow preserves audit trails and can streamline administrative handling.

Why a Complete, Compliant Claim Form Matters

Who Typically Prepares or Signs This Form

The form is completed and submitted by several parties depending on the situation.

  • Policyholders or beneficiaries submitting their own claims for reimbursement after paying eligible medical expenses.
  • Employers or plan administrators filing on behalf of employees under group benefits arrangements.
  • Healthcare provider billing or office staff when assignment of benefits or provider certification is required.

Each signer should confirm identity, attach itemized receipts, and retain a copy for records.

Stepwise Completion Process

Follow these sequential steps to prepare and submit a typical extended health care claim.

  • 01
    Gather: Collect itemized receipts, provider statements, and policy ID prior to starting the form.
  • 02
    Complete: Fill all required fields, using MM/DD/YYYY for dates and full legal names for parties.
  • 03
    Authorize: Sign the claimant declaration and any provider assignment or release of information.
  • 04
    Submit: Send the form and attachments through the insurer's accepted channel—portal, mail, or secure email.

Where and How Claims Are Submitted

Claims can be sent through multiple channels; choose the method your plan specifies to avoid processing delays.

  • Insurer Portal: Upload form and receipts via secure claims portal for fastest processing.
  • Mail: Send original receipts and signed form to the mailing address on the policy booklet.
  • Secure Email / Fax: If allowed, submit using the insurer's secure email or designated fax number.
  • Broker Submission: Submit through your broker or plan administrator when they manage group claims.

Configuring an Online Submission Workflow

If you digitize the form, set required fields and notifications to reduce incomplete submissions.

Field | Configuration Field Name | Required / Auto-validate
Claimant Name Required | Auto-capitalize and exact-match validation
Policy Number Required | Regex validation for expected format
Attachment Upload Required | Accept PDF, JPG; limit 25 MB per file
Signature Required | Electronic signature with audit trail

Technical Requirements for eSubmission and eSignatures

Electronic submission requires secure transport, document integrity, and signer authentication to meet legal and privacy expectations.

  • File Formats: PDF, DOCX accepted; PDF preferred for fixed layout and attachments.
  • Security: TLS encryption in transit and AES-256 at rest are recommended for PHI.
  • Authentication: Email, SMS OTP, or stronger methods required by plan for certain claims.

Use platforms that support audit trails, retention, and, where needed, HIPAA Business Associate Agreements to protect patient data.

Timing Considerations and Typical Deadlines

Timelines vary by plan; submit promptly and review your policy for plan-specific filing windows and appeal deadlines.

Prompt Submission:

Submit claims as soon as possible after expenses are incurred.

Plan Filing Window:

Many plans require submission within 90 days to one year; verify your policy booklet.

Appeals Window:

Appeal deadlines differ by insurer and plan—check your denial notice.

Reimbursement Timing:

Adjudication timelines vary; insurers typically communicate expected timelines.

Record Retention:

Keep originals until claim and any appeal are fully resolved.

Key Processing Milestones from Submission to Payment

Typical milestone sequence outlines what to expect while a claim moves through adjudication and payment.

01

Submission Received

Insurer logs the claim and issues an acknowledgment to the submitter.

02

Initial Review

Claims team verifies policy coverage, eligibility, and receipt completeness.

03

Medical / Financial Adjudication

Services and amounts are reviewed against plan terms for allowable reimbursement.

04

Decision & Payment

Claim is approved or denied; payments issued or appeals instructions provided.

Common Errors That Slow or Deny Claims

  • Missing or illegible receipts that prevent verification of eligible expenses.
  • Incorrect policy numbers or claimant names that misroute the claim for manual review.
  • Unsigned declarations or missing provider certification when assignment is required.
  • Uploading photos of receipts with partial images or unacceptable file types causing rejection.

Potential Consequences of Incomplete or Incorrect Claims

Claim Denial: Non-payment or partial payment
Processing Delays: Extended adjudication time
Appeal Burden: Additional documentation required
Incorrect Payment: Overpayment recovery actions
Privacy Risk: Unauthorized PHI exposure
Recordkeeping Gaps: Difficulty substantiating future claims

Security and Compliance Essentials for Claims Handling

PHI Protection: HIPAA compliance and a signed BAA where required
Transport Encryption: TLS 1.2/1.3 recommended
Data at Rest: AES-256 encryption recommended
Audit Trail: Signed timestamps, IPs, and action logs
Access Controls: Role-based access and activity monitoring
Regulatory Standards: SOC 2 and ISO controls where applicable

Core Sections of a Professional Claim Submission

Each section of the form serves a validation purpose: identity, eligibility, expense substantiation, and legal authorization.

Claimant Details

Collect full legal name, contact information, policy number, and claimant relationship to ensure correct plan association and contact routing during adjudication.

Patient Details

Provide patient name, date of birth, and relationship to the claimant to confirm dependent eligibility and match records within the insurer's system.

Service Line Items

List each service or item with date(s), provider, CPT or service code if known, and individual costs to support accurate adjudication and benefit calculation.

Receipts and Proof

Attach original, itemized receipts or provider invoices showing service dates, descriptions, and paid amounts to substantiate reimbursement requests.

Provider Certification

When required, include provider signature, license or tax ID, and proof of medical necessity for certain services to meet plan requirements.

Authorization

Claimant signature or electronic consent authorizes release of information and payment instructions; required to process many claims.

Accepted Formats, Attachments, and Recordkeeping

Prepare attachments and storage copies according to insurer guidelines to ensure submissions are accepted and auditable.

Accepted Formats

PDF is preferred for fixed layout; JPEG/PNG acceptable for photos of receipts. Ensure files are legible and under size limits specified by the insurer.

Required Attachments

Include original itemized receipts, provider invoices, and any pre-authorization letters. Scans must clearly show service dates and amounts.

How to Save

Keep a copy of the completed form and PDFs of attachments in secure storage for the required retention period and for appeals if needed.

Audit Copies

Retain signed copies with audit trail evidence when submitted electronically to show intent and the sequence of events.

Representative eSignature Pricing and Feature Comparison

Compare core pricing and compliance features for common eSignature vendors. signNow appears first in the comparison per platform conventions.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Primary Signer Roles and Responsibilities

Policyholder / Claimant

The policyholder or beneficiary signs to certify the accuracy of the claim, to authorize release of medical information if required, and to direct reimbursement instructions; they must provide identity verification and retain copies for possible appeals or audits.

Provider / Representative

A provider or billing representative may complete provider sections, certify services rendered, and sign any assignment of benefits; they must include identifying numbers and legible documentation to support billed charges.

Real-World Claim Scenarios

Two concise scenarios illustrate common workflows and documentation practices for extended health care claims.

Employer-Sponsored Plan

A covered employee pays for out-of-network therapy and submits itemized receipts and a signed claim form

  • The plan requires provider invoices and proof of payment
  • After complete documentation the claim is adjudicated and the employee receives reimbursement directly or via payroll reimbursement depending on plan settings.

Individual Policyholder

An individual pays a specialist co-pay and files a claim with original receipts and treatment dates

  • The form requires patient DOB and provider tax ID
  • The insurer requests one follow-up clarification, after which the claim is processed and the policyholder is notified of the decision.

FAQs and Troubleshooting for Common Claim Issues

Answers to frequent questions about completing, signing, and submitting the Manulife Affinity Markets Extended Health Care Claim Form.


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