Formulaire de refus de réclamation

REFUS DE RÉCLAMATION - DEMANDE

Claim number

Reason for refusal

Insurance Plan Holder

Name of your client

(this may be the spouse or one of the plan holder's children)

Name of insurance company

Plan Number

(Enter n/a if not applicable)

Certificate Number

(Enter n/a if not applicable)

Participant Number

(Enter n/a if not applicable)

Date of services rendered

Amount of consultation

Date of services rendered - 2nd consultation

Amount of 2nd consultation

Name of therapist

NAN Member's ID Number

Copy of the refusal letter (PDF format, or JPG/HEIF photo)

Select file

Comment(s)

If you are human, leave this field blank.

members

change of address

Besoin de nous signaler un changement d'adresse?

CHANGEMENT D'ADRESSE - DEMANDE

Your Name

First Name

Last Name

Enter your email again

NAN Member's ID Number

Which address are you replacing?

Address to replace

# and street

Address (line 2)

City

Province

Postal Code

Telephone

New Address - including the apt./suite # (if applicable)

# and street

Address (line 2)

City

Province

Postal Code

Telephone

Comment(s)

If you are human, leave this field blank.

refusal of claim

Vous voulez nous signaler le refus de réclamation d'un assureur?

REFUS DE RÉCLAMATION - DEMANDE

Claim number

Reason for refusal

Insurance Plan Holder

Name of your client

(this may be the spouse or one of the plan holder's children)

Name of insurance company

Plan Number

(Enter n/a if not applicable)

Certificate Number

(Enter n/a if not applicable)

Participant Number

(Enter n/a if not applicable)

Date of services rendered

Amount of consultation

Date of services rendered - 2nd consultation

Amount of 2nd consultation

Name of therapist

NAN Member's ID Number

Copy of the refusal letter (PDF format, or JPG/HEIF photo)

Select file

Comment(s)

If you are human, leave this field blank.