Medical Provider Form

If you're a medical provider looking to submit a claim for a patient, complete the form below and we'll get back to you as soon as we can.

Please submit only 1 claim per webform.

Provider name

Please enter your first and last name

Provider number

Please enter your provider number

Provider phone number

Please enter a contact phone number

Provider contact email address

Please enter the provider contact email address

Member name

Please enter the name of the person claiming

Member number

Please enter the HIF member number

Will there be a charge?

Please select one

Additional information

Please enter any supporting information for your claim

Supporting documents

Please upload any relevant documents to support your claim

Ask us a question
Enter a question or keyword. eg. 'What is..', 'How do I..'

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