Reimbursement request and
direct deposit registration

Are the costs incurred as a result of an accident at work? yesno
Are the costs incurred as a result of an automobile accident? yesno

Details of the member

Incurred expenses

Submit a claim for your Cost Plus or Health Care Spending Account: :

  • If your insurance contract does not cover the submitted expenses, attach the original of each receipt. If it's a claim for dental care, please attach the dentist form duly completed.
  • If your insurance contract covers part of the submitted expenses, attach a copy of each receipt and the payment slip of insurer.

Submit a claim for your Ded/co:

  • Attach a copy of each payment slip from the insurer detailing the deductible and/or co-insurance
Individual Name Date of birth Total
Total

Pre-authorized Registration

Electronic copy of voided check

Transmission of receipts

Attach a copy of all your receipts

  1. With the voided check, I authorize Interfas inc. to make deposits in my bank account.
  2. Please note that the reimbursement of benefits by check is made on the last Friday of each month.

Contact us

1 866 877.7243