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. 

Please enter first and last name
Please enter provider number
Please enter a contact phone number
Please enter the provider contact email address
Please enter the first and last name of the HIF member claiming
Please enter the HIF member number
Please select one
Please enter any supporting information for your claim
Please upload any relevant documents to support your claim