Government of New Brunswick

Medicare Payments, Account and Delegate Authorization Forms

 

What form do I need?

Form Name Must be completed when...
Medicare Account Request Form – Single Service Provider An individual practitioner requires additional Medicare billing account(s);
  • Salaried physicians must have an On-call account and a Shadow-billing account;
  • A physician doing Sessional work may require a Shadow-billing account;
  • A physician doing Alternate Funding Plan (AFP) work may require a Shadow-billing account.
Medicare Account Request Form – Multiple Service Providers A group of practitioners requires additional Medicare billing account(s);
  • For the same reason as those listed above for the Medicare Account Request Form – Single Service Provider or;
  • The group establishes an unincorporated group practice, and each service provider in the group wishes to authorize Medicare to direct payment for services billed to this account, such as a walk-in clinic. Medicare issues only one statement and one payment for this type of account.
Medicare Account Form – Add/Remove a Practitioner A practitioner needs to be added to an already existing Medicare billing account.  
Medicare Account - Delegate Authorization Form An already existing Medicare billing account not delegated to the Regional Health Authority needs:
  •  A new delegate or;
  • Information on a current delegate needs to be updated (including removing a delegate).

Agreement –Delegation of a Regional Health Authority

Form for delegating the Health Authority:

Horizon

Vitalité

 A physician chooses to appoint one of the two Regional Health Authorities to act on their behalf for matters relating to the said account(s) such as:
  • Transmitting/submitting claims;
  • Viewing Reconciliation Statements within the Electronic Communication to Physician (ECP) system.
RHA Delegate Request Form Adding or deleting access to the Electronic Communication to Physician (ECP) system for RHA employees.

For any questions, please contact us at [email protected] or at (506) 453-8274.