1 Information on the invoice 2 Fin webform_started Request a reimbursement for covered services obtained outside Québec Renseignements sur la facture Information on the invoice First and last names of the professional who provided the services Name of the clinic, pharmacy or hospital Payment of the invoice Invoice paid in full Invoice paid in part Unpaid invoice Date of payment Example: 31/01/2020Thirty-one, then slash, then zero one, then slash, then twenty twenty Total amount of the invoice Amount $ Currency - Select -AED – United Arab Emirates DirhamAFN – AfghaniALL – Albanian LekAMD – Armenian DramANG – Netherlands Antillean GuilderAOA – KwanzaARS – Argentine PesoAUD – Australian DollarAWG – Aruban FlorinAZN – Azerbaijani ManatBAM – Convertible MarkBBD – Barbadian DollarBDT – TakaBGN – Bulgarian LevBHD – Bahraini DinarBIF – Burundian FrancBMD – Bermudan DollarBND – Brunei DollarBOB – BolivianoBRL – Brazilian RealBSD – Bahamian DollarBTN – Bhutanese NgultrumBWP – Botswanan PulaBYR – Belarusian RubleBZD – Belize DollarCAD – Canadian DollarCHF – Swiss FrancCLP – Chilean PesoCNY – Chinese YuanCOP – Colombian PesoCRC – Costa Rican ColónCUC – Cuban Convertible PesoCUP – Cuban PesoCVE – Cape Verdean EscudoCZK – Czech Republic KorunaDJF – Djiboutian FrancDKK – Danish KroneDOP – Dominican PesoDZD – Algerian DinarEGP – Egyptian PoundERN – Eritrean NakfaETB – Ethiopian BirrEUR – EuroFJD – Fijian DollarFKP – Falkland Islands PoundGBP – British Pound SterlingGEL – Georgian LariGGP – Guernsey PoundGHS – Ghanaian CediGIP – Gibraltar PoundGMD – Gambian DalasiGNF – Guinean FrancGTQ – Guatemalan QuetzalGYD – Guyanaese DollarHKD – Hong Kong DollarHNL – Honduran LempiraHRK – Croatian KunaHTG – Haitian GourdeHUF – Hungarian ForintIDR – Indonesian RupiahILS – Israeli New SheqelIMP – Manx PoundINR – Indian RupeeIQD – Iraqi DinarIRR – Iranian RialISK – Icelandic KrónaJEP – Jersey PoundJMD – Jamaican DollarJOD – Jordanian DinarJPY – Japanese YenKES – Kenyan ShillingKGS – Kyrgystani SomKHR – Cambodian RielKMF – Comorian FrancKPW – North Korean WonKRW – South Korean WonKWD – Kuwaiti dinarKYD – Cayman Islands DollarKZT – Kazakhstani TengeLAK – Laotian KipLBP – Lebanese PoundLKR – Sri Lankan RupeeLRD – Liberian DollarLSL – Lesotho LotiLTL – Lithuanian LitasLVL – Latvian LatsLYD – Libyan DinarMAD – Moroccan DirhamMDL – Moldovan LeuMGA – Malagasy AriaryMKD – Macedonian DenarMMK – Myanma KyatMNT – Mongolian TugrikMOP – Macanese PatacaMRO – Mauritanian OuguiyaMUR – Mauritian RupeeMVR – Maldivian RufiyaaMWK – Malawian KwachaMXN – Mexican PesoMYR – Malaysian RinggitMZN – Mozambican MeticalNAD – Namibian DollarNGN – Nigerian NairaNIO – Nicaraguan CórdobaNOK – Norwegian KroneNPR – Nepalese RupeeNZD – New Zealand DollarOMR – Omani RialPAB – Panamanian balboaPEN – Peruvian Nuevo SolPGK – Papua New Guinean KinaPHP – Philippine PesoPKR – Pakistani RupeePLN – Polish ZlotyPYG – Paraguayan GuaraniQAR – Qatari RialRON – Romanian LeuRSD – Serbian DinarRUB – Russian RubleRWF – Rwandan FrancSAR – Saudi RiyalSBD – Solomon Islands DollarSCR – Seychellois RupeeSDG – Sudanese PoundSEK – Swedish KronaSGD – Singapore DollarSHP – Saint Helena PoundSLL – Sierra Leonean LeoneSOS – Somali ShillingSRD – Surinamese DollarSTD – São Tomé and Príncipe DobraSVC – Salvadoran ColónSYP – Syrian PoundSZL – LilangeniTHB – BahtTJS – SomoniTMT – Turkmenistani ManatTND – Tunisian DinarTOP – PaʻangaTRY – Turkish LiraTTD – Trinidad and Tobago DollarTWD – New Taiwan DollarTZS – Tanzanian ShillingUAH – Ukrainian HryvniaUGX – Ugandan ShillingUSD – United States DollarUYU – Urugayan PesoUZS – Uzbekistan SomVEF – BolivarVND – DongVUV – VatuWST – TalaXAF – CFA Franc BEAC Description of the services Examples: examination, surgery, consultation, purchase of medications, etc. Joindre un fichier Attach a file Attached files All documents are required. Any missing document will delay the processing of your application. You must provide documents in English or French.The total size of the files must not exceed 15 MB.Accepted formats: PDF and image (JPG).Invoice and proof of paymentFor each service received, you must attach the invoice and proof of payment showing that you paid the invoice (examples: receipt, cash sales slip, mention “Paid” stamped on the invoice). Select a file Fichiers joints Other documents (optional)Attach any other documents that may be useful in analyzing your application.If the application concerns major surgery, attach the operation report.If you have power of attorney to act on behalf of another person, you can attach it to your application. Select a file Leave this field blank
