Get Formulaire 4314 - Demande De Remboursement D'une Personne Assur E. Demande De Remboursement D'une

Filling out the Formulaire 4314 is the first step in seeking reimbursement for covered health services. This guide provides clear instructions for complete and accurate submission of the form online.

Follow the steps to successfully fill out the Formulaire 4314 online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Complete section 1 by providing information about the healthcare professional, including last name, first name, and professional number.
3. In section 2, fill out information about the insured person: their last name at birth, health insurance number, first name at birth, date of birth, and gender.
4. In section 3, input details regarding the covered services, including billing code, date of services, description of the service provided, amount received, place of service, and total amount.
5. In section 4, the healthcare professional must sign and certify that the services listed were provided. Ensure all required information is completed.
6. For section 5, the insured person must provide their home address. If there is a change of address, direct them to follow the instructions provided.
7. In section 6, the insured person or their representative must sign the form, indicate their relationship to the insured, and provide necessary contact information.
8. Once all sections are filled, review the form for completeness and accuracy. You can save changes, download, print, or share the form as necessary.

Complete and submit your Formulaire 4314 online today for a smoother reimbursement process.