Sample Medical Supplies and Equipment Claim Form

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Sample Medical Supplies and Equipment Claim Form

Client Surname
The surname under which the client is registered as an eligible First Nations or recognized Inuit client.

Client Given Name
The given name under which the client is registered as an eligible First Nations or recognized Inuit client. Submission of more than one given name is preferred to facilitate client verification. Initials are not acceptable.

Client Date of Birth (dd/mm/yyyy)
The client's full birth date in day-month--year format (for example, 13/05/1992 represents 13 May 1992). Partial birth dates are not acceptable.

Code: Client Identification No.
A unique number used to identify a client who is eligible to receive benefits under the NIHB Program. This number may be one of:

• 9 or 10-digit number issued to eligible First Nations clients by the Department of Indian and Northern Affairs Canada (INAC);
• 3-digit band number, immediately followed by the 4 or 5-digit family number identifying the family unit within the eligible First Nations client's band;
• An alpha prefix followed by an 8-digit number issued to certain eligible First Nations and recognized Inuit clients by First Nations and Inuit Health Branch ( FNIHB ); or
• Health care number issued to recognized Inuit clients by the Government of the Northwest Territories and the Government of Nunavut.

Band No.
A 3-digit number (for example, 002, 311) identifying the band to which an eligible First Nations client belongs. The band number, when submitted in combination with the client's family number, is an acceptable alternative to the client identification number for an eligible First Nations client.  

Family No.
A 4 or 5-digit number (for example, 1041, 04120) identifying the family unit within the band to which an eligible First Nations client belongs. The family number, when submitted in concert with the client's band number, is an acceptable alternative to the client identification number for an eligible First Nations client. If the family number on the eligible First Nations client's registration card has fewer than 5 digits, please insert the appropriate number of zeros in front of the number.

Date of Service (dd/mm/yyyy)
The date on which service was provided to the client, in day-month- year format (for example, 13/05/1992 represents 13 May 1992).

DIN/Item Code
The Drug Identification Number (DIN) or item code.  

Quantity
The quantity (number of units) of the item dispensed.

Prescription No.
The prescription number assigned by your pharmacy for the item dispensed.

Drug/Item Cost
The total ingredient or acquisition cost for all units of the drug or item dispensed.

Dispensing Fee
The dispensing fee for the item dispensed. Leave blank if not applicable.

Markup
The dollar amount of any mark-up for the item, based on the established percentage. Leave blank if not applicable.

Third-Party Share
The dollar amount of any portion of the claim which is billable to a provincial or territorial program or other third party. Leave blank if not applicable.

Amount Claimed
The sum of the drug/item cost, dispensing fee, and mark-up for the item, less any third-party share.

Days Supply
Estimate of number of days of treatment contained in the prescription.

Total
The total dollar amount claimed for all items (up to 3) listed on the claim form.

Prescriber
The prescriber number as entered by the provider on the claim submission must be the same as required by the provincial/territorial pharmacare program. Claims for repair, labour, and replacement parts must be submitted with '999Repair' in the prescriber field or they will be rejected on the NIHB Pharmacy Claim Statement with an R14 error (Insufficient Benefit Information to Adjudicate Claim).

• British Columbia Physician License Number
• Alberta Physician License Number
• Saskatchewan Physician's Provincial Billing Number
• Manitoba Physician License Number
• Ontario Physician License Number
• Quebec Physician License Number
• New Brunswick Physician's Provincial Billing Number
• Nova Scotia Physician License Number
• Prince Edward Island Physician License Number
• Newfoundland Physician License Number
• Yukon Physician's Territorial Billing Number
• Northwest Territories Physician License Number
• Nunavut Physician License Number

Prior Approval No.
An authorization number, which must be issued by FNIHB before the provider dispenses certain drugs, medical supplies and most medical equipment (Health Canada NIHB Drug Exception Centre for drugs and the FNIHB Regional Office for Medical Supplies and Equipment).

Pharmacy Name
The name of the pharmacy submitting the claim, may be formatted as determined by the pharmacy.

Pharmacy Address
The address of the pharmacy submitting the claim, may be formatted as determined by the pharmacy.  

Pharmacy Number
The number assigned to the pharmacy upon registration as an NIHB provider.

Parent Information (Required For Infants Less Than One Year of Age)

Parent's Surname
The surname under which the parent is registered as an eligible First Nations or recognized Inuit client.  

Parent's Given Names
The given names under which the parent is registered as an eligible First Nations or recognized Inuit client. Submission of more than one given name is preferred to facilitate client verification. Initials are not acceptable.  

Parent's Date of Birth (dd/mm/yyyy)
The parent's full birth date in day-month--year format (for example, 13/05/1956 represents 13 May 1956). Partial birth dates are not acceptable.  

Parent's Client Identification No.
The number under which the parent is identified as an eligible First Nations or recognized Inuit client. This number may be one of:

• 9 or 10-digit number issued to eligible First Nations clients by the Department of Indian and Northern Affairs Canada (INAC);
• 3-digit band number, immediately followed by the 4 or 5-digit family number identifying the family unit within the eligible First Nations client's band;
• An alpha prefix followed by an 8-digit number issued to certain eligible First Nations and recognized Inuit clients by FNIHB, or
• Health care number issued to recognized Inuit clients by the Government of the Northwest Territories and the Government of Nunavut.

Parent's Band No.
A 3-digit number (for example, 002, 311) identifying the band to which an eligible First Nations client's parent belongs. The band number, when submitted in combination with the family number, is an acceptable alternative to the client identification number for an eligible First Nations client.

Parent's Family No.
A 4 or 5-digit number (for example, 1041, 04120) identifying the family unit, within the band, to which an eligible First Nations client's parent belongs. The family number, when submitted in combination with the band number, is an acceptable alternative to the client identification number for an eligible First Nations client. If the family number on the eligible First Nations client's registration card has fewer than 5 digits, please insert the appropriate number of zeroes in front of the number.