We’ve created this handy form to help you tell us what your patient needs. The form will help eliminate questions and errors and streamline the insurance claim process. Click the the image to download a fillable pdf of the form.

How to use this form:

  • Click the image to initiate the download.
  • Select a location to save the pdf file (example: Documents folder).
  • Open the file from the saved location and complete the appropriate sections.
  • Print a copy for your patient or send the completed form by fax to 204-727-5882.
  • Close the file without saving. The form will be reset and ready to use again.