Get Client Reimbursement Form - First Nations Health Authority - Fnha 2020-2025

The Client Reimbursement Form of the First Nations Health Authority is designed to assist individuals in claiming eligible health benefits for services received. This guide will provide clear, step-by-step instructions to ensure a smooth online completion of the form, making the process easier for all users.

Follow the steps to complete the Client Reimbursement Form online.

1. Press the ‘Get Form’ button to access the Client Reimbursement Form and open it in your editor.
2. Complete Part 1 – Client Information. Fill in your surname, first and middle names, address details, identification number, city, province/territory, telephone number, postal code, and date of birth. Also include your Personal Health Number (PHN) and indicate if you are covered for any expenses under other health plans.
3. In Part 2, provide the information for a parent, guardian, or the person to whom payment should be made, if different from you. This includes their surname, first and middle names, address, identification number, city, province/territory, telephone number, postal code, date of birth, PHN, and their relationship to you.
4. Fill in Part 3 – Details of Claim. List the benefit items you are claiming (e.g., prescription drugs, medical supplies, etc.) along with the total cost for each item, and calculate the total amount you are claiming.
5. In Part 4 – Authorization and Signature, authorize the release of any necessary records related to this claim. You must confirm that the information provided is accurate and sign your name along with the date.
6. Review all entries for accuracy, ensuring all necessary documents are attached as per the instructions provided with the form.
7. Finally, save the completed form. You can then choose to download, print, or share the form for submission.

Start filling your Client Reimbursement Form online today to ensure you receive the health benefits you are entitled to.