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Name:
Terry Doe
Customer Care number:
00000001
Claim number:
12345678
Name:
John Doe
Customer Care number:
00000001
Expense details
Date of service or purchase
Name of retailer or provider
If you are requesting reimbursement for health care services, please provide the name of the clinic and the practitioner, if available.
Registration number
(optional)
If you are requesting reimbursement for health care services, please provide the registration or license number of the practitioner, if available.
Quantity or number of units
For example, number of sessions or number of packages.
Cost per unit (not including taxes)
For example, the cost of one session or one package.
$
PST
(if paid)
$
GST or HST
(if paid)
$
Total: $
0
Your receipt
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