|Classification / Identification:|
| ||Form Number:||014-0000-80||Edition date: ||2003/10 |
| ||Title:||Out of Province Claim for Physician Services|
| ||Ministry:||Health and Long-Term Care|| || |
| ||Branch/ABC:||ADM - Negotiations and Accountability Management|| || |
| ||Program:||ADM - Negotiations and Accountability Management|| || |
| ||Purpose of Form:||Under Interprovincial agreement, for travel within Canada, patients/physicians submit form to get reimbursed by applicable health plan.|| || |
You must download Adobe Acrobat Reader (version 10.0 or above) to view/print PDF forms.
Click here for further instructions.
If PDF forms do not open in the latest versions of Firefox and Chrome, click here for the solution.
Protecting Your Information:
If you are using this online service on a shared computer in a public area (i.e. public library), it is important to ensure that you do not leave the computer unattended while accessing the service. Before leaving the computer, it is also important that you fully exit the application, clear your browser's cache (This link opens in a new window)
and close down your browser. This will ensure that no one else can access any personal information you may have entered.