Hlth 2814-2026

1. Click ‘Get Form’ to open hlth 2814 in the editor.
2. Begin with Section A, where you will input patient information. Fill in the patient's last name, first name(s), birthdate, gender, and personal health number (PHN). Ensure all details are accurate.
3. Continue by providing contact information including home and work phone numbers, mailing address, and residential address if different. Confirm residency by answering the question about living at the provided address for the past six months.
4. In Section B, detail the medical attention received. Specify the reason for seeking medical care, treatment or procedure performed, and include amounts paid along with proof of payment.
5. For hospital claims in Section C, enter the hospital's name and address, admission and discharge dates, and any relevant details regarding your stay. Attach proof of payment for hospital charges.
6. Finally, review all sections for completeness before signing at the end of the form. Ensure that all necessary receipts are attached as instructed.

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