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

Request a reimbursement for covered services

Unless otherwise indicated, answer all the questions.

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