|Classification / Identification:|
| ||Form Number:||014-4890-84E||Edition date: ||2020/07 |
| ||Title:||Request for Access to Personal Claims History (PCH) Information by Individual or Individual's Substitute Decision Maker|
| ||Ministry:||Health|| || |
| ||Branch/ABC:||Claim Services Branch|| || |
| ||Program:||Claims Services|| || |
| ||Purpose of Form:||Receive information required to process Personal Claims History information requests from individuals or individual's substitute decision makers.|| || |
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