Claims Calculator

Enter your claim(s) information in the form below. Upon completion click the "Generate Printable Expense Report" button to generate a completed printable claims form.

NOTE: You will require Adobe Acrobat Reader to view the auto-generated form. Download it free from Adobe.

* * *
ITEM # DATE (D/M/Y) PATIENT NAME TYPE OF EXPENSE AMOUNT

1

$

2

$

3

$

4

$

5

$

6

$

7

$

8

$

9

$

10

$

11

$

12

$

13

$

14

$

15

$

16

$

17

$

18

$

19

$

20

$


Attention Required


I am enrolled with Direct Deposit.

I would like to sign up for Direct Deposit. (Please complete this form and submit to CustomCare along with your claim) - This will waive the fee.

I would like to receive a cheque. I understand there is a $10 charge to receive a manual cheque and it will be added to my claim.