Benefit forms

The Public Service Health Care Plan forms are found on the PSHCP Member Services website

List of forms available:

• Application form for active and retired members
• Prior Authorization form
• Claim forms (regular and out-of-country)
• Veterans Affairs Canada Application and Amendments forms

The PSHCP Relief Provision application form is found on the Public Services and Procurement Canada website.

Here you can access forms for the Public Service Dental Care Plan (PSDCP).

• Claim Form for Public Service Dental Care Plan (PSDCP) (PDF Document – 155 KB) (The Canada Life Assurance Company)
• Public Service Dental Care Plan (PSDCP) - Authorization for Claims Submission and Redirection of Payment (PDF Document - 80 KB) (The Canada Life Assurance Company)
• Public Service Dental Care Plan (PSDCP) Dependant Information Form (PDF Document - 130 KB) (The Canada Life Assurance Company)

Here you can access forms for the Pensioners’ Dental Services Plan (PDSP).

• Claim Form (PDF Document - 54 KB - Sun Life Financial)
• Pensioners’ Dental Services Plan (PDSP) Authorization for Claims Submission and Re-direction of Payment Form

Note: If you are about to retire, you can obtain the Pensioners’ Dental Services Plan (PDSP) form (used to enrol, amend or terminate PDSP coverage) from the Government of Canada Pension Centre. If you are already retired or become entitled to a survivor benefit, you can obtain the PDSP form from the Pension Centre.

Here you can access forms for the Public Service Management Insurance Plan (PSMIP).

• The four claim forms for the Public Service Management Insurance Plan - Long-Term Disability (PSMIP-LTD) benefits can be found on the Industrial Alliance PSMIP-LTD website. They include the:
  • Employee’s Statement (F54-1011A-57)
  • Attending Physician’s Questionnaire (F54-1014A-57 for a mental health condition), or (F54-1015A-57 for a musculoskeletal condition), or (F54-1016A-57 for all other medical conditions)
  • Employer’s Statement (F54-1012A-57 to be completed by the immediate supervisor or manager)
  • Employer’s Statement (F54-1013A-57 to be completed by departmental compensation/Human Resources advisor)
• PSMIP Claim Form for Accidental Dismemberment Benefit (Forms number TBS 5954 & 5955)
• PSMIP Claim Form for Death Benefit (Forms number TBS 5948 & 5949)
• Form 2027 - Long-term Disability Insurance – PSMIP PWGSC
• Form 2027-1 - Long-term Disability Insurance – PSMIP (Part-time Employee Only) PWGSC
• Form 2028 - PSMIP PWGSC
• Form 2028-1 - PSMIP (Change of Name or of Beneficiaries) PWGSC
• Form 2028-5 - PSMIP Part-time employee only PWGSC
• Form 2028-7 - PSMIP – Members Entitled to Government-Paid Coverage PWGSC
• Form 2451-1 - Post-retirement Life Insurance Plan (Change of Name/Change of Beneficiary)

The Disability Insurance Plan claim forms below can be found on the Sun Life DI webpage: www.sunlife.ca/DI.

• Employee’s Statement (490L-M-12500-E)
• Attending Physician’s Questionnaire (490L-P-12500-GEN-E, 490L-P-12500-MHC-E, or 490L-P-12500-MSK-E)
• Employer’s Statement (Immediate Supervisor or Manager)(4841-E)
• Employer’s Statement (Compensation Advisor)(4811-E)