Claim Form
Submit this claim form and original receipts to your employer


PROMEDENT ADMINISTRATION INC.
Head Office, 2066 Qualicum Drive, 1st Floor, Vancouver, BC, V5P 2M2
Tel 604.327.2022   Fax 604.324.1762   www.promedent.ca
(hereinafter called "Promedent")
Employer Legal Business Name: ________________________________________________________
Business Address: ___________________________________________________________________
City: _____________________________________ Province: ______________ Postal: ____________
Employee Name: ____________________________________________________________________
Address: ___________________________________________________________________________
City: _____________________________________ Province: ______________ Postal: ____________
Payment
Date
Patient
Name
Relationship Payment
made to
Description Payment
Amount
Claim
Amount
             
             
             
             
             
             
             
             
             
             
TOTAL CLAIM AMOUNT TO BE REIMBURSED    

Description With Electronic
Funds Transfer ("EFT")
Without Electronic
Funds Transfer ("EFT")
Total Claim Amount to be reimbursed    
Administration Fee with GST (GST# 89758 4314 RT0001)    
Administration Fee with HST (HST# 89758 4314)    
Payment to Promedent Administration Inc.    

The employee indicated above, will be issued a reimbursement cheque or EFT. Please allow up to 30 days for processing.

I agree to hold harmless Promedent Administration Inc., its directors and employees, who accept no responsibility or liability for any damages, penalties or assessments of income tax that may arise from this claim.


Signature of employee: ________________________________ Date: _____________________________

As an authorized representative of the above Employer, I request that the expenses listed above be reimbursed on a cost-plus basis. I confirm that such expenses qualify as medical expenses under Section 118.2(2) of the Income Tax Act and are within the claimant's annual reimbursement limit.


Signature of employer: __________________________________________ Date: _____________________________


Employee instructions:   Submit this claim form and original receipts to your employer.
 
Employer instructions:   Retain copies for audit purposes. Once you have electronically approved this claim, you will not be required to submit any written documents to Promedent if you are using EFT. If you are manually submitting this form, you must send a copy of this form with a cheque to Promedent Administration Inc., Head Office, 2066 Qualicum Drive, 1st Floor, Vancouver, BC V5P 2M2.
 
  If you are manually submitting a cheque, you must submit a signed copy of this claim form with your cheque to Promedent, 2066 Qualicum Drive, Vancouver, BC V5P 2M2.