Government of Ontario: Ministry of Health

Name and mailing address of Ontario hospital

Summary of Inpatient Expenses

Attention: Supervisor of Reciprocal Billing

Enclosed are statements of inpatient expenses incurred in the treatment of the residents of other provinces, as summarized below, for the month ending .

Province

British Columbia: Amount
Alberta: Amount
Saskatchewan: Amount
Manitoba: Amount
Québec: Amount
New Brunswick: Amount
Nova Scotia: Amount
Prince Edward Island: Amount
Newfoundland Labrador: Amount
Nunavut: Amount
Northwest Territories: Amount
Yukon Territory: Amount
Total: Amount

I certify that these amounts were not previously billed, nor billed in whole or in part, to any other party.

Authorized Signature