1 A quel nom 2 Your identity 3 Your contact information 4 information on the services received 5 Description of the services to be reimbursed 6 Page des pièces jointes 7 Next 8 Fin webform_started Request a reimbursement for covered services Unless otherwise indicated, answer all the questions. In what capacity are you filing the application? In what capacity are you filing the application? In what capacity are you filing the application? On my behalf On behalf of someone else Form submission language:Relation with the sender:Identity of the person who received the services:Contact information:Information on the clinic that billed the services:Information on the heath professional who rendered the services:Description of the services to be reimbursed:Services paid due to an expired card or a card not presentedHealth professional’s practice number:Category of health professional:Explanations or comments:Services paid due to an expired card or a card not: ext.apt.Have lost the entitlement to free services due to a change in his situation (birthday or other) between March 16 and September 1, 2020Attached documents Leave this field blank
