Form Hc/nihb - Nihb Client Reimbursement Request Form printable pdf download

Health Canada Protected

First Nations and Inuit Health Branch

Non-Insured Health Benefits (NIHB) Program

NIHB Client Reimbursement Request Form

Information you need to include with your completed client reimbursement form can be found on the next page of this form. Please

note that all NIHB policies and requirements for coverage apply. All requests for reimbursement of eligible benefits must be

made within one year from the date of service.

It is important to submit ALL related documents or there will be a delay in processing your claim. Please keep copies for

your files.

Part 1 – Client Information

(client receiving the service)

Surname:

First and Middle Names:

Address:

Apt.:

Identification Number:

City:

Province/Territory:

Telephone number: (

)

Postal Code:

Date of Birth:

(YYYY/MM/DD)



Are you covered for any of these expenses under any other health plan(s)/program(s)? No

Yes

If yes, please attach a copy of a detailed statement or explanation of benefits form from all other plan(s)/program(s).

Part 2 – Parent, Guardian or Person to whom payment should be made

Please provide the name and address of the person to whom payment should be made if different from client receiving the service. If

client is under one year of age and not registered, please provide parent or guardian information. The person must also be over the

provincial/territorial legal age.

Surname:

First and Middle Names:

Address:

Apt.:

Identification Number (if applicable):

City:

Province/Territory:

Telephone number: (

)

Postal Code:

Date of Birth:

(YYYY/MM/DD)

Relationship to Treated Client:

Part 3 – Details of Claim

Instructions on what information is needed to be included with the completed client reimbursement form are listed on the next page. Fill

in the total of all receipts for each category.

List Benefit Items Requested: (

Prescription drugs, Medical Supplies & Equipment, Vision and Eye Care,

Cost

)

Medical Transportation or Dental/Orthodontic Benefits

TOTAL AMOUNT CLAIMED:

Part 4 – Authorization and Signature (Mandatory)

I authorize the release of any records that are relevant to the processing and payment of all claims held by the service provider to

Health Canada, it’s agents or contractors, or any appropriate Health Professional licensing or Regulatory Body for the purpose of

administrative audit. I declare the information to be true and accurate and does not contain a claim for any benefit or service previously

paid for by Health Canada or by any other plan(s)/program(s) that is noted in the statement or explanation of benefits.

Client, Parent, Guardian or Person having a legally recognized authority

Date:

(YYYY/MM/DD)

Print Name:

Signature:

Forms that are not signed will be returned to the client for signature

Privacy statement

Health Canada also requires your authorization in order to collect information from your medical provider for services provided to you

and paid for by the Non-Insured Health Benefits Program. The NIHB Program is committed to protecting your privacy and safeguarding

the personal information in its possession. When a request to provide coverage for benefits is received, the NIHB Program collects, uses,

discloses and retains your personal information in accordance with the applicable federal privacy laws and policies. Further details of the

NIHB Privacy Code can be found on the Health Canada website:

HC/NIHB –January 2013

Form Hc/nihb - Nihb Client Reimbursement Request Form

Related Articles

Related forms

Related Categories