Emr reimbursement form 2026

1. Click ‘Get Form’ to open the emr reimbursement form in the editor.
2. Begin by filling out the Clinic Information section. Enter your clinic name, address (including suite number), city, postal code, phone, and fax number.
3. In the Costs section, specify the period costs incurred by entering the date in 'yyyy-mm' format. List each vendor's name, description of services, and total costs incurred. Ensure all amounts include GST.
4. Proceed to the Allocation of Costs section. List all physicians associated with your clinic along with their AMA numbers. Optionally, indicate their percentage and dollar amount of reimbursement.
5. Ensure that each physician signs next to amounts exceeding $1,500. If additional space is needed for more physicians, attach a separate sheet labeled 'Additional Physician Information.'
6. Finally, certify the information provided by signing as an authorized representative and including your printed name and title. Submit the completed form via email or fax as indicated.

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