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ClaimSecure Hospital Bed Assessment (2002000-021A-CL)

ClaimSecure uses this assessment to pre-approve the purchase or rental of a hospital bed under a plan member's benefits. The physician gives the diagnosis, prognosis and how long the patient will need the bed, while the supplier quotes manual and electric bed costs. ClaimSecure notifies the claimant in writing about plan coverage once all required information has been assessed.

Who completes it

The prescribing physician signs Part 3 and completes Part 4 (current medical information) in full. The claimant completes Parts 1 and 2 and signs the authorization, and the supplier completes Part 5 with rental and purchase prices.

Submitting and payment

How to submit it
The completed form is returned to ClaimSecure with the estimate and supporting documentation by mail, fax or email.

Good to know

  • Hospital bed benefits through ClaimSecure are supplemental to the provincial assistive devices program, so the claimant should verify provincial eligibility before applying.
  • Part 4 is brief: the diagnosis, the prognosis and the expected length of time the patient will need the hospital bed.
  • The supplier's Part 5 quotes monthly rental and purchase costs for both a manual and an electric hospital bed.
  • Fields must be completed in pen using blue ink, and the form must be complete to avoid delays in assessing the claim.

Get the official form

Download the current version from the source each time; forms change without notice.

Hospital Bed Assessment Form

Official pagePDF

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

When is the ClaimSecure hospital bed assessment needed?

ClaimSecure asks for the form when a hospital bed estimate is submitted, with all required information completed before approval. It covers both purchase and rental, and ClaimSecure notifies the claimant in writing about plan coverage once the information has been assessed.

What does the physician complete on the ClaimSecure hospital bed form?

The prescribing physician gives their name, contact details and signature in Part 3, then completes Part 4 in full with the diagnosis, the prognosis and the expected length of time the patient will need the hospital bed. The supplier completes the cost section.

Does the provincial plan need to be contacted first?

Yes. ClaimSecure asks claimants to contact their provincial plan to verify eligibility before applying, because its hospital bed benefit is supplemental to the provincial assistive devices program. Part 2 asks whether a portion will be covered by the provincial plan and, if not, why.