PlanMembers-Forms – RWAM Website

planmember-form

Forms

Online claim submission is available via RWAM Plan Member Services.

If you have questions or need assistance filling out a form please contact RWAM.

Health & Dental Claims Forms

Extended Health Claim Form | RC001

Dental Claim Form | CDA Website

Visit CDA Website

Out-of-Canada/ Out-of-Province Travel Claims

Out-of-Canada / Out-of-Province Claim Submission Summary | RC067

Out-of-Canada / Out-of-Province Claim Form | A003CF

Specialty Forms for Claims

Prior Authorization Request | RC058

Brand Name Drug Exception Form | RC054

RC054 is only applicable to plans with Mandatory Generic guidelines.

Health Spending Account (HSA) Claims

HSA – Stand Alone | RC002

EHC/HSA – 1 Certificate | RC020b

EHC/HSA – 2 Certificate | RC020

Stop Waiting for your Money – Submit your Claims Electronically

Find out how by visiting the Claim Submission Guidelines page.

Coordination of Benefits (COB)

Coordination of Benefits Form | RA104

Updating Personal Information

Employee’s Direct Deposit of Groups Benefits Payments | RA014

Change in Status/ Name/ Primary Beneficiary Form | RA077

Beneficiary Designation/ Change | RA086

Irrevocable Beneficiary Designation | RA182

Declaration of Student Eligibility | RA042

Out-of-Province/ Canada Coverage Extension Request for Student Study/Work Term | RA100