AREA CODE
TELEPHONE NUMBER
DATE OF ACCIDENT
SIGNATURE OF PATIENT (If other than patient, state relationship to patient) DATE
DATE OF DEPARTURE FROM
HOME PROVINCE/TERRITORY
OUT-OF-PROVINCE CLAIM
FOR PHYSICIAN SERVICES
PATIENT’S LAST NAME ON HEALTH CARD FIRST NAME
PROVINCE/TERRITORY
PERMANENT MAILING ADDRESS
YEAR
YEAR MONTH MONTH
MONTH
YEAR
YEAR
DAY DAY
DAY
MONTH DAY
M F
SEXBIRTHDATE NAME OF PARENT / GUARDIAN
A To be completed by Patient or Representative (please type or print clearly)
MUNICIPALITY
PLACE WHERE TREATED (PROVINCE, TERRITORY)
POSTAL CODE
IS THIS A PERMANENT
MOVE?
MEDICARE NUMBER
CARD EXPIRY DATE
RELATIONSHIP TO PATIENT
YES NO
IF YES, INDICATE THE MOVE DATE
SPACE RESERVED FOR ADMINISTRATIVE PURPOSES
HEALTH PROFESSIONAL’S LAST NAME FIRST NAME
I hereby declare, conscientiously believing it to be true and knowing it to have the same effect as if it were made under oath and by virtue of
the Canada Evidence Act, that the information given above is correct and that I am a beneficiary of the Medical Care Plan in the
province/territory of
TELEPHONE NO. (Home)TELEPHONE NO. (Work)
AREA CODEAREA CODE
B Declaration of Patient or Representative
C To be completed by Health Professional (please type or print clearly)
VACATION STUDY BUSINESS OTHER: (specify)
GIVE REASON
FOR ABSENCE
FROM HOME
4292 266 15/02
FRENCH
LANGUAGE OF CORRESPONDENCE
HEALTH PROFESSIONAL’S SIGNATURE
DATEI accept the patient’s plan payment as payment in full.
DATE OF
SERVICE
PROCEDURE/TREATMENT FEE CODE FEE TIME
DIAGNOSIS AND OTHER REMARKS
CLAIM INVOLVES:
ANESTHETIST
PSYCHIATRIST
SURGICAL
ASSISTANT
HRS MINS
NAME OF REFERRING PHYSICIAN
DURATION OF TREATMENT
NAME OF BUSINESS (IF APPLICABLE) IF APPLICABLE
GENERAL PRACTITIONER SPECIALIST
SPECIALITY
ADDRESS
D Description of services delivered
POSTAL CODE
MUNICIPALITYNUMBER STREET
PROVINCE OR TERRITORY
WORK ACCIDENT AUTOMOBILE ACCIDENT
OTHER : (specify)
ENGLISH
X
YEAR
YEAR MONTH DAY
MONTH DAY
DISCHARGE DATEADMISSION DATENAME AND ADDRESS OF HOSPITAL IF ITS SERVICES WERE USED
REIMBURSEMENT
TO PATIENT
PAYMENT TO
HEALTH PROFESSIONAL
PAYMENT
TO BUSINESS
SPECIALITY
YEAR MONTH DAY
DATE OF RETURN TO
HOME PROVINCE/TERRITORY
OFFICE HOSPITAL
IN-PATIENT
HOSPITAL
OUT-PATIENT
EMERGENCY
ROOM
HOME
Place where the services were rendered
X
DAY DAYMONTH MONTHYEAR YEAR
YEAR MONTH DAY HRS MINS
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