|Classification / Identification:|
| ||Form Number:||014-0951-84E||Edition date: ||2021/02 |
| ||Title:||Out-of-Province/Out-of-Country Claim Submission|
| ||Ministry:||Health|| || |
| ||Branch/ABC:||Claim Services Branch|| || |
| ||Program:||Claims Services|| || |
| ||Purpose of Form:||Form used so patient can submit out of country medical receipts|| || |
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