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www.gov.nt.ca » HSS » Programs and Services » Supplementary Health Benefits » Provider Forms
Extended Health Benefits

Supplementary Health Benefits

Provider Forms

Dental

  • Important information for dental providers — November 2012
  • EHB Dental-related medical travel prior approval form

Medical Supplies and Equipment

  • Important information for medical supplies and equipment providers — Feb. 2012
  • EHB Medical supplies and equipment prior approval form
  • Important information for medical equipment and supplies providers — November 2012
  • EHB Medical supplies/equipment and associated travel prior approval form

Prescription Drugs

  • Biosimilars Initiative Support: Patient List Request — Dec. 2021
  • EHB Request for Exception Drug Coverage

Vision

  • Important information for optical providers—Feb. 2012
  • EHB Optical Prior Approval Form
  • EHB Optical Claim Form

Supplementary Health Benefits

  • Application Forms
  • Notices of Changes to Prescription Drug Administration
  • Provider Forms
  • Resources

Contact Us

Health Services Administration Office
Health and Social Services
Bag #9
Inuvik, NT X0E 0T0
  • Toll-free
    1-800-661-0830
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    1-867-678-8050
  • Fax
    1-867-777-3197
healthcarecard@gov.nt.ca
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Government of Northwest Territories