Important Note

• Plan Members must complete this form, even if your patient or customer is the Plan Member's dependent
• We refer to the Provider as "you or "Provider"
• You keep the completed form on file for verification purposes for the later of (i) 6 years following the last service date or (ii) such longer period as required by applicable law or the regulations and professional standards of your regulatory body, college or association.
  Plan means a group benefits plan or an individual policy of insurance.
  Plan Member means for group plans, the eligible member (e.g. for an employer group plan, this is the employee) responsible for the group benefits coverage. For individual insurance policies, the Plan Member is the policyholder. Plan Members’ dependents are eligible for coverage. Dependents are the Plan Member’s spouse or children.
  Plan Sponsor is the policyholder of an insured or self-insured group benefits plan. For example, for Plans covering employees, the Plan Sponsor is the Plan Member’s employer.Provider refers to licensed or qualified paramedical practitioner, ophthalmologist or optometrist providing medical services or goods. A Provider may be
• An organization, such as a facility or clinic, submitting claims on behalf of one or more healthcare practitioners; or
• An individual responsible for their own billing.

In the Sun Life Electronic Claims Submission Agreement, we refer to the above as a Healthcare Practice and Independent Healthcare Provider respectively