Claim Form for PRE-AUTHORIZED PLAN

Name: Direct Reimbursement Associates Ltd.
Address: Box 388, Pincher Creek, AB, T0K 1W0, Canada
Telephone: 4036325226

Date*

Business or Company Name*

Name of Covered Employee*

Employee Email Address*

Employee Phone Number*

Patient Name*

Service Date*

Description of Service*

Amount*

Total Claim 0