Claim Form – Program Regarding Bandages and Compression Garments Used to Treat Lymphedema

This form is used to apply for a reimbursement of the cost of supplies purchased from a provider that has not signed an agreement with RAMQ. Must be accompanied by the original invoices and proofs of payment, as well as a medical prescription in the case of a first application.

To find out more about the procedure, refer to the page Compression garments for lymphedema.

Note: You must save the claim form on your computer and open it with Adobe Acrobat Reader software.

Form 4258