A-520 NIHB Personal Reimbursement Check List

A-520 Non-Insured Health Benefits Personal Reimbursement Check List

NIHB Personal Reimbursement Check List

Non-Insured Health Benefits
Check List for Personal Reimbursements

If you have purchased an item that is a benefit under the Non-Insured Health Benefits program and are
seeking reimbursement, the following checklist must be
completed in order for the claim to be processed.
If any of the requirements are missing, then the claim will be returned to you unprocessed.
Claims must be submitted within one year of the purchase.

Please make the reimbursement payable to:

Name

Phone Number

Where you can be reached during the day

Mailing Address

City/Town

State/Province

ZIP/Postal Code

Proof of Payment

Must be the Original cash registered receipt.
One file only.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

If you unable to provide a cash register receipt, please indicate reason why:

Lost Receipt

Paid by someone else

(please explain)

Other (please explain)

Enter other…

Original Receipt from Provider

i.e. Taxi, Hotel, Meals
One file only.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Signature of Claimant

Sign above

Date

Send this claim directly to:
Nunavut Health Insurance Programs
Department of Health
Box 889
Rankin Inlet, NU
X0C 0G0
Phone: 1-867-645-8001
Toll Free: 1-800-661-0833
E-mail: @email

Steps

Current NIHB Personal Reimbursement Check List
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A-520 NIHB Personal Reimbursement Check List

Non-Insured Health Benefits Check List for Personal Reimbursements

Steps

Non-Insured Health Benefits
Check List for Personal Reimbursements