Form Hc/nihb - Nihb Client Reimbursement Request Form Page 2
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1
2Health Canada Protected
First Nations and Inuit Health Branch
Non-Insured Health Benefits (NIHB) Program
INFORMATION YOU NEED TO INCLUDE WITH YOUR COMPLETED CLIENT REIMBURSEMENT FORM
FOR ALL BENEFITS:
Original receipt(s) for proof of payment. Credit card/Debit (Interac) slips are not acceptable forms for proof of payment.
o
Sign and complete all applicable parts of this NIHB Client Reimbursement Request Form. Forms that are not signed will be returned to the
o
.
client for signature
Please see exceptions to the Dental /Orthodontic and Medical Transportation Benefits below.
If applicable, submit your detailed statement or explanation of benefits form from all other health plan(s)/program(s). Note: Original receipts
o
are not required when submitting the detailed statement or explanation of benefits form as the primary insurer requires them. In such cases, a
copy of the original receipt is acceptable.
In addition to the items listed above, please submit the specific requirements for the benefits listed below:
Prescription Drugs
No additional information other than what is listed above is required.
Medical Supplies and Equipment, Vision & Eye Care
A copy of your prescription.
Dental or Orthodontic Services (Please note: For the reimbursement of Dental or Orthodontic Services only, you may use the NIHB Dental
Claim Form (Dent-29 Form) OR an NIHB Client Reimbursement Request Form). When using an NIHB Client Reimbursement Request Form
you must also submit ONE of the following completed claim forms provided by the dental or orthodontic service provider:
Association des Chirurgiens Dentistes du Québec Dental Claim and Treatment Plan Form
Standard Dental Claim Form
Canadian Association of Orthodontics Information Form
Medical Transportation
(Please note: When submitting for reimbursement specifically for medical transportation only, you may use the NIHB
Client Reimbursement Request Form OR a regional specific medical transportation form provided by the Health Canada regional office).
Proof of your medical appointment attendance.
MAILING INSTRUCTIONS
For all reimbursements , please mail your completed form(s) and receipt(s) to the applicable Health Canada Regional Office, Orthodontic Review
Centre or National Dental Predetermination Centre.
BC Region
Alberta Region
Saskatchewan Region
Non-Insured Health Benefits
Non-Insured Health Benefits
Non-Insured Health Benefits
First Nations and Inuit Health
First Nations and Inuit Health
First Nations and Inuit Health
Health Canada
Health Canada
Health Canada
757 West Hastings Street, Suite 540
9700 Jasper Avenue, Suite 730
2045 Broad Street, 4th Floor
Vancouver, British Columbia V6C 3E6
Edmonton, Alberta T5J 4C3
Regina, Saskatchewan S4P 3T7
Telephone (toll-free): 1-800-317-7878
Telephone (toll-free): 1-800-232-7301
Telephone (toll-free): 1-800-667-3515
Dental (toll-free): 1-888-321-5003
Dental (toll-free): 1-800-232-7301
Dental (toll-free): 1-877-780-5458
Manitoba Region
Ontario Region
Quebec Region
Non-Insured Health Benefits
Non-Insured Health Benefits
Non-Insured Health Benefits
First Nations and Inuit Health
First Nations and Inuit Health
First Nations and Inuit Health
Health Canada
Health Canada
Health Canada
391 York Avenue, Suite 300
1547 Merivale Road, 3rd floor
200 René-Lévesque Boulevard West
th
Winnipeg, Manitoba R3C 4W1
Postal Locator 6103A
Guy-Favreau Complex, 4
floor
Telephone (toll-free): 1-800-665-8507
Nepean, Ontario K1A OL3
Montréal, Québec H2Z 1X4
Dental (toll-free): 1-877-505-0835
Telephone (toll-free): 1-800-640-0642
Telephone (toll-free): 1-877-483-1575
Dental (toll-free): 1-800-640-0642
Dental (toll-free): 1-877-483-5501
Atlantic Region
Northern Region (NWT & Nunavut)
Northern Region (Yukon)
Non-Insured Health Benefits
Non-Insured Health Benefits
Non-Insured Health Benefits
First Nations and Inuit Health
First Nations and Inuit Health
First Nations and Inuit Health
Health Canada
Health Canada
Health Canada
1505 Barrington Street
Qualicum Building
300 Main Street, Suite 100
th
Suite 1525, 15th Floor, Maritime Centre
2936 Baseline Rd., Tower A – 4
Floor
Whitehorse, Yukon Y1A 2B5
Halifax, Nova Scotia B3J 3Y6
Ottawa, Ontario K1A 0K9
Telephone (toll-free): 1-867-667-3942
Telephone (toll-free): 1-800-565-3294
Telephone (toll-free): 1-888-332-9222
Dental (toll-free): 1-888-332-9222
Dental (toll-free): 1-800-565-3294
Dental (toll-free): 1-888-332-9222
ORTHODONTIC REVIEW CENTRE
NATIONAL DENTAL PREDETERMINATION CENTRE
Non-Insured Health Benefits
Non-Insured Health Benefits
First Nations and Inuit Health Branch
First Nations and Inuit Health Branch
Health Canada
Health Canada
nd
nd
200 Eglantine Driveway, 2
Floor, Jeanne Mance Bldg.
200 Eglantine Driveway, 2
Floor, Jeanne Mance Bldg.
Address Locator 1902C
Address Locator 1902D
Ottawa, Ontario K1A OK9
Ottawa, Ontario K1A OK9
Telephone: 1-866-227-0943
Toll free: 1-855-618-6291
Fax: 1-866-227-0957
Fax: 1-855-618-6290
HC/NIHB –January 2013
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