"Request for Approval for Temporary Fee-For-Service Billing by a Salaried Physician" - Newfoundland and Labrador, Canada

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Government of Newfoundland and Labrador
Department of Health and Community Services
Physician Services Division
Request for Approval for Temporary Fee-for-Service Billing by a Salaried Physician
In accordance with the Agreement between Government and the NLMA, salaried physicians are eligible to bill on a FFS
basis when they are on approved leave of absence from the employer. Such an arrangement requires further approval
from the Physician Services Division of the Dept. of Health and Community Services. To be considered for approval, this
form must be completed by the employer.
R
H
B
:
EGIONAL
EALTH
OARD
P
N
:
ROVIDER
AME
P
N
:
ROVIDER
UMBER
D
F
-
-S
B
:
F
:
T
:
ATE OF
EE
FOR
ERVICE
ILLING
ROM
O
H
F
-
-S
B
:
F
:
:
T
:
:
OURS OF
EE
FOR
ERVICE
ILLING
ROM
O
T
S
P
:
YPE OF
ERVICE
ROVIDED
E
D
C
I
:
MERGENCY
EPARTMENT
OVERAGE
NSTITUTION
S
A
/ C
I
:
URGICAL
SSIST
LINIC
NSTITUTION
T
L
:
YPE OF
EAVE
P
C
:
AID
OMMENT
U
NPAID
A
M
D
D
PPROVED BY
EDICAL
IRECTOR OR
ELEGATE
For Physician Services Use Only
DOHCS A
:
Y
N
PPROVED
ES
O
Privacy Notice
Under the authority of the Medical Care Insurance Act, 1999, personal information is collected in order to administer the Medical Care Plan (MCP). This information is
kept confidential and handled as required by the Access to Information and Protection of Privacy Act (ATIPP). Any questions or comments can be directed to Brian
Bennett, Manager of Physician Services, Department of Health and Community Services, at (709) 729-3148 or BrianDBennett@gov.nl.ca.
P.O. Box 8700, St. John’s, NL A1B 4J6 Tel: (709)729-3508, Fax: (709) 729-5238
Government of Newfoundland and Labrador
Department of Health and Community Services
Physician Services Division
Request for Approval for Temporary Fee-for-Service Billing by a Salaried Physician
In accordance with the Agreement between Government and the NLMA, salaried physicians are eligible to bill on a FFS
basis when they are on approved leave of absence from the employer. Such an arrangement requires further approval
from the Physician Services Division of the Dept. of Health and Community Services. To be considered for approval, this
form must be completed by the employer.
R
H
B
:
EGIONAL
EALTH
OARD
P
N
:
ROVIDER
AME
P
N
:
ROVIDER
UMBER
D
F
-
-S
B
:
F
:
T
:
ATE OF
EE
FOR
ERVICE
ILLING
ROM
O
H
F
-
-S
B
:
F
:
:
T
:
:
OURS OF
EE
FOR
ERVICE
ILLING
ROM
O
T
S
P
:
YPE OF
ERVICE
ROVIDED
E
D
C
I
:
MERGENCY
EPARTMENT
OVERAGE
NSTITUTION
S
A
/ C
I
:
URGICAL
SSIST
LINIC
NSTITUTION
T
L
:
YPE OF
EAVE
P
C
:
AID
OMMENT
U
NPAID
A
M
D
D
PPROVED BY
EDICAL
IRECTOR OR
ELEGATE
For Physician Services Use Only
DOHCS A
:
Y
N
PPROVED
ES
O
Privacy Notice
Under the authority of the Medical Care Insurance Act, 1999, personal information is collected in order to administer the Medical Care Plan (MCP). This information is
kept confidential and handled as required by the Access to Information and Protection of Privacy Act (ATIPP). Any questions or comments can be directed to Brian
Bennett, Manager of Physician Services, Department of Health and Community Services, at (709) 729-3148 or BrianDBennett@gov.nl.ca.
P.O. Box 8700, St. John’s, NL A1B 4J6 Tel: (709)729-3508, Fax: (709) 729-5238