Canvet Claim Center Form – Fill Out and Use This PDF

CANVET CLIENT CLAIM FORM

1.ALL RELEVANT FIELDS OF this BOX MUST BE COMPLETED. ATTACH ORIGINAL BILLS, RECEIPTS,

STATEMENTS ETC. COPIES WILL BE DENIED AND THE CLAIM WILL BE RETURNED

Section A

CanVet ID			Family Name		Given Name
	Telephone Number		Mailing Address
	Section B – Amount Claimed
Date of Service or		Service Description and Total KM		Amount Claimed $		*Pay Institution
Purchase (dd/mm/yy)						(tuition only)

Travel for an assessment was involved in this claim (Not for school)

From address:	Time Departed:	dd/mm/yyyy time
To address:	Time Arrived back at departure point:		dd/mm/yyyy time
Purpose of Travel:

1.I have attached original receipts, vouchers, electronic tickets and other backup documentation as required

2.I have read the claims guidelines, understand the claim requirements for this program and agree that changes to my claim may be necessary to ensure compliance with the rules for reimbursement

3.I understand that a claim for reimbursement must be made within ONE YEAR of expenditure

4.I understand that decisions regarding payment of my claim and the rules for reimbursement are made by Veterans Affairs Canada

5.I certify that I have received the above benefits/services. I certify that, to the best of my knowledge, the information on this form is true and complete and does not contain a claim for any expenses previously paid for by this or any other plan. If I already have health and dental coverage from other sources, I will be responsible for opting-out of any health and dental coverage offered by my training institution where possible and applicable.

Signature: ________________________________________ Date: ________________________________________

The personal information provided on this form is collected under the authority of The Canadian Forces Members and Veterans Re-establishment and Compensation Act for the purpose of facilitating the reimbursement of benefits and services. Provision of the information is voluntary.

The personal information collected on this form is protected from unauthorized disclosure by the Privacy Act. The Privacy Act also provides individuals with a right of access to personal information about themselves under the control of the Department, as well as a right to challenge the accuracy and completeness of their personal information and have it amended as appropriate.

For further information on the above statement, contact the Access to Information and Privacy Coordinator’s Office, Veterans Affairs Canada, PO Box 7700, Charlottetown, PE, C1A 8M9.

In order to obtain prompt payment of your claim, did you…

Complete and sign your claim form?

Include original receipts (NO Photocopies OR Faxes)?

Staple all receipts and documentation to the claim?

Include documentation from the educational institution indicating that the following items are

“required”: books, tools, safety clothing, software, equipment, etc (see documentation)?

List mileage by day or week showing each day that was traveled?

Provide a rationale if travel occurred during a weekend or statutory holiday?

Verify that you have the most recent copy of your Individual Vocational Rehabilitation Plan (IVRP)?

If you do not, please contact your VAC Case Manager.

Payment of this claim does not indicate that all future claims for these items or services will be approved.

Claims for reimbursement must be made in writing within one year after the day on which the

expenditure was incurred. Claims submitted after that date will be declined.

When Completed, Please Mail Your Claim Form to

CanVet VR Services

Client Claim Processing Centre

5th Floor, 915 Fort Street

Victoria, BC

V8V 3K3

Missing or incorrect information results in unavoidable delays in claims payment.

For questions view our website at WWW.CANVETSERVICES.COM.

Decisions regarding payment of your claim and the rules for reimbursement are made by Veterans

Affairs Canada.