Medical Reimbursement Form

A. GENERAL INFORMATION
1. Please complete this form and hit submit upon completion.
2. Athletes must pay the service provider directly for the service they receive.
3. Upload copies of invoices and receipts for all expenses and itemize them by providing all the information requested.
4. Include any required physician referrals or orders.
5. All athletes MUST first utilize other reimbursement options such as their own personal health plan or health plans of parents/guardians, spouse, etc. that they are eligible to receive benefits from. The Medical Services/Treatment Program is to be utilized only when other options are not available or the athlete has maximized the available benefit limits of other eligible plans. Documentation from other plans must be submitted to verify that maximized limits have been reached in order to receive funding from the Medical Services/Treatment Program.
6. Reimbursements will be paid out on a monthly basis. The deadline for submissions is the 30th of each month. Late submissions will be carried over to the next submission deadline.
7. For more information or if you have any questions regarding your claim, contact Travis Laycock travis.laycock@sasktel.net toll free 1.888.350.5558 Ext 1.
B. PRIVACY
The Sport Medicine and Science Council of Saskatchewan (SMSCS) and the Canadian Sport Centre Saskatchewan (CSCS) respects your privacy. Your personal information will be used only for the purposes of assessing your claim and administering this program.
C. ELIGIBLE SERVICES
1. Initial Injury Assessment
2. Physical Therapy
3. Athletic Therapy
4. Massage Therapy
5. Chiropractic Services
6. Acupuncture
7. Orthotics (with an M.D. order)
8. Sport Bracing (with an M.D. order)
9. Special Circumstances – In rare situations, other services may be considered.
D. (NEW) ELIGIBLE PROVIDERS
1. The SMSCS and its professional members/consultants are the providers of service that athletes are EXPECTED to utilize. These individuals are the sport experts within their professional medical designations. A complete listing of these service providers is available at the SMSCS’s website at smscs.ca.
2. It should be noted that the SMSCS does not have a specific listing of service providers for Acupuncture, Orthotics, and Sport Bracing.
3. In the event that the individuals listed on the SMSCS’s website are not available or there is no one located in the athlete’s area, then other registered professionals may be accepted.
E. DECLARATION
1. I declare the statements made herein are true and complete.
2. I warrant that I have made this application for reimbursement knowing that I am not eligible to claim these expenses through any other health or benefits plan.
3. I understand that any misrepresentation, incorrect or concealed information or failure to fully complete all sections of this form may void my eligibility to receive reimbursement.
4. I release the SMSCS, CSCS, and the health care provider(s) from legal action resulting from advice and treatment given to the athlete and I hereby release the SMSCS, the CSCS, and the health care provider(s) from all liability and agree not to institute legal action with regard to that advice and treatment.
5. I declare that, if I am signing on behalf of any person(s), I have the authority to sign on behalf of such person(s) listed herein and confirm that each of the above declarations and authorization are also provided on behalf of that person(s).