®*the blue cross symbol and name, colour of caring and mybluecross are registered marks of the canadian association of blue cross plans, independently licensed by manitoba blue cross. *†blue shield is a registered trade-mark of the blue cross blue shield association.. The blue cross symbol and name are registered marks of the canadian association of blue cross plans, an association of independent blue cross plans. licensed to the manitoba blue cross plan. mbc 1180 pdf-10/2009. The blue cross symbol and name are registered marks of the canadian association of blue cross plans, an association of independent blue cross plans. licensed to the manitoba blue cross plan. dd. mm yr. dd mm. yr.
Blue cross – cancellation request; blue cross – loss of coverage form; blue cross – notice of change form; blue cross – health benefits claim form; blue cross – dental claim form; blue cross – pre-authorized debit application for leave of absence; blue cross – brochure for mybluecross; great-west life forms. mps 103 – change of. Claim forms use these forms to submit your health and dental claims to the insurance company. photocopies of blank claim forms may also be used. please allow one to two weeks for your claim to be processed. where to send health & dental claims: manitoba blue cross (to the address indicated on the form) ambulance claim form. Extended health benefits claim form p.o. box 1046, winnipeg, manitoba r3c 2x7 phone 775-0151 or toll free within manitoba 1-800-use-blue (1-800-873-2583) group blue cross contract no. surname claimant first name street, p.o. box no city town village postal code.
