Private Health Services Plan Forms

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For opening a new Brock Health Private Health Services Plan (PHSP)

1. Registration Form (downloadable pdf form)

1a. Registration Form (online form)

For plans with more than one Covered Employee, complete this form as well

2. Appendix A – Eligible Claimant Information (downloadable pdf form)

2a. Appendix A – Eligible Claimant Information (online form)

To set up a Prepaid Plans complete this form as well. Please call for assistance with this form

3. Appendix B – Prepaid Plan Configuration (downloadable pdf form)

3a. Appendix B – Prepaid Plan Configuration (online form)

For unincorporated businesses complete this form as well

4. Appendix C – Sole Proprietorship Details (downloadable pdf form)

4a. Appendix C – Sole Proprietorship Details (online form)

For making a claim – Pay-As-You-Go plans

5. Pay-As-You-Go Plan Claim Form – (Manual PDF Version) – Download, print and complete by hand in pen
6. For Atlantic Canada customers – Pay-As-You-Go Plan Claim Form – (Spreadsheet Version) – Complete, Save and Print
7. For ON customers – Pay-As-You-Go Plan Claim Form – (Spreadsheet Version) – Complete, Save and Print
8. For all other customers – Pay-As-You-Go Plan Claim Form – (Spreadsheet Version) – Complete, Save and Print

For making a claim – Prepaid plans

9. Prepaid Plan Claim Form

Pre-Authorized Electronic Payments

10. Direct Deposit Request – for electronic transfers FROM Brock Health TO employee claimants
11. Pre-Authorized Debit Agreement – for electronic transfers FROM Planholder Business TO Brock Health

Online Claim Payments

12. Online Claim Payment Form