Please select from the list below to access the form you require.
- Administration Forms
- Claim Forms
- Prescription Drugs Requiring Special Authorization
- Other Special Authorization Forms
All of the forms on OTIP Services are posted as pdf files. You will require a copy of Adobe Reader to access these files. Download your free copy. If you are unable to access these files, please contact OTIP benefits services at 1-866-783-6847 or by e-mailing questions@otipservices.com to have a copy of the form mailed to you.
Application for Insurance and Evidence of Insurability
When applying for coverage more than 31 days after becoming eligible, complete and submit this form along with your application. Plan members under the RTIP/ARM plans will need to complete this form if they wish to change their coverage under the plan.
Plan members who have life coverage and wish to change their designated beneficiary must complete this form. This form must be signed, dated and witnessed.
Plan members whose plan allows for continuation of coverage during a leave of absence must complete this form whether or not they choose to maintain or discontinue coverage.
Complete this form if you are new member and wish to apply for coverage.
Plan members who need to change their health and dental single/family coverage status, add or remove dependants must complete this form. This form must be signed and dated.
Overage Dependant Student Form
Plan members who have dependant children over the age of 21 and still in full-time attendance at an accredited post-secondary education facility must complete this form annually to continue coverage for their dependant child until they reach the contract termination age or are no longer in full-time attendance at school.
Pre-Authorized Chequing Authorization Form
Plan members may choose to have their premium deducted monthly from their bank account. Join our convenient, pre-authorized monthly payment plan by submitting a completed PAC authorization form and a personal cheques, marked VOID for verification purposes.
Claimants requiring reimbursement for dental care expenditures must have this form completed by their dentist, or dental specialist. Original receipts and applicable supporting documentation must accompany all claim submissions.
Extended Health Benefit Claim Form
Claimants seeking reimbursement for extended health care benefits such as prescription drugs can complete this form and submit it by mail to the address listed on the form. Original receipts and applicable supporting documentation must accompany all claim submissions.
By completing this form, a plan member authorizes OTIP to pay the service provider directly for the eligible costs associated with a claim. Please note that fees for services not covered under a benefit plan, and fees in excess of the coverage provided under a benefit plan will be the financial responsibility of the plan member.
Vacation Supply Form - RTIP - ARM
RTIP/ARM plan members will need to complete this form if they wish to purchase more than a 3 month supply of prescription medication to take on their vacation.
Prescription Drug Special Reimbursement Form
Certain medications and drug therapies require pre-authorization by OTIP and its Insurer prior to the commencement of treatment. The claimant's attending physician must complete this form describing the claimant's underlying medical condition, previous treatment history outcomes and medical criteria for the treatment request.
List of Prescription Drugs Requiring Special Authorization
Pre-authorization by OTIP and its Insurer is required for certain drugs and medicines. Drugs identified in the list of Prescription Drugs Requiring Special Authorization normally require a Prescription Drug Special Reimbursement Form be completed by the plan member's attending physician. Review of the plan member's underlying medical condition will determine patient eligibility; or identify if coordination with the Ministry of Health or drug manufacturer is required. Once the plan member has been approved for any drug identified in List 1, the pharmacist has the ability to submit subsequent claims for the drug online. Exception: if the plan member has been approved for more than one drug and the drugs fall withinn different therapeutic categories, subsequent claims must continue to be submitted manually. For those drugs identified in List 2, pre-approved drug claims must continue to be submitted manually. The pharmacist cannot submit these drugs online. Should you have any questions regarding your specific plan design, the drug listings or the procedure for submitting requests for reimbursement, please call OTIP benefits services.