Government of Ontario: Ministry of Health

Reciprocal Claim

Confidential when completed

Ministry use

Provider Number
Province
Registration Number
Date of Birth (yyyy/mm/dd)
Account Number
Payment Prog.
Payee
Referring Provider Number
Master Number
Inpatient Admission (yyyy/mm/dd)
Patient’s Surname
Patient’s First Name
Sex


Service Code	Fee Submitted	No. of Services	Service Date yyyy/mm/dd	Diagnostic Code
1. Service Code	1. Fee Submitted	1. No. of Services	1. Service Date (yyyy/mm/dd)	1. Diagnostic Code
2. Service Code	2. Fee Submitted	2. No. of Services	2. Service Date (yyyy/mm/dd)	2. Diagnostic Code
3. Service Code	3. Fee Submitted	3. No. of Services	3. Service Date (yyyy/mm/dd)	3. Diagnostic Code
4. Service Code	4. Fee Submitted	4. No. of Services	4. Service Date (yyyy/mm/dd)	4. Diagnostic Code
5. Service Code	5. Fee Submitted	5. No. of Services	5. Service Date (yyyy/mm/dd)	5. Diagnostic Code
6. Service Code	6. Fee Submitted	6. No. of Services	6. Service Date (yyyy/mm/dd)	6. Diagnostic Code
7. Service Code	7. Fee Submitted	7. No. of Services	7. Service Date (yyyy/mm/dd)	7. Diagnostic Code
8. Service Code	8. Fee Submitted	8. No. of Services	8. Service Date (yyyy/mm/dd)	8. Diagnostic Code
9. Service Code	9. Fee Submitted	9. No. of Services	9. Service Date (yyyy/mm/dd)	9. Diagnostic Code
10. Service Code	10. Fee Submitted	10. No. of Services	10. Service Date (yyyy/mm/dd)	10. Diagnostic Code

4421–84 (2020/03) © Queen’s Printer for Ontario, 2020

7530–5655

fold here

For Ministry Use Only

Registration No. / Prov. Code missing/incorrect
Date of Birth missing/incorrect
Payment Program is missing/invalid
Payee is missing/incorrect
Please resubmit as Health Claim

For Ministry Use Only- Missing/Incorrect Service

Referring Provider No.
Master Number
Admission Date
Service Code
Fee
Number of Services
Service Date
Diagnostic Code
Missing/Incorrect information as highlighted on claim card
Date
Station

Please detach here and return the top portion to the ministry. The bottom portion is a copy for your records.

Providers’s Copy

Government of Ontario: Ministry of Health

Reciprocal Claim

Confidential when completed


Service Code	Fee Submitted	No. of Services	Service Date yyyy/mm/dd	Diagnostic Code
1. Service Code	1. Fee Submitted	1. No. of Services	1. Service Date (yyyy/mm/dd)	1. Diagnostic Code
2. Service Code	2. Fee Submitted	2. No. of Services	2. Service Date (yyyy/mm/dd)	2. Diagnostic Code
3. Service Code	3. Fee Submitted	3. No. of Services	3. Service Date (yyyy/mm/dd)	3. Diagnostic Code
4. Service Code	4. Fee Submitted	4. No. of Services	4. Service Date (yyyy/mm/dd)	4. Diagnostic Code
5. Service Code	5. Fee Submitted	5. No. of Services	5. Service Date (yyyy/mm/dd)	5. Diagnostic Code
6. Service Code	6. Fee Submitted	6. No. of Services	6. Service Date (yyyy/mm/dd)	6. Diagnostic Code
7. Service Code	7. Fee Submitted	7. No. of Services	7. Service Date (yyyy/mm/dd)	7. Diagnostic Code
8. Service Code	8. Fee Submitted	8. No. of Services	8. Service Date (yyyy/mm/dd)	8. Diagnostic Code
9. Service Code	9. Fee Submitted	9. No. of Services	9. Service Date (yyyy/mm/dd)	9. Diagnostic Code
10. Service Code	10. Fee Submitted	10. No. of Services	10. Service Date (yyyy/mm/dd)	10. Diagnostic Code