Claim for External Breast Prostheses Reimbursement Program form (NH005)

Use this form to claim a reimbursement for new or replacement breast prostheses you purchased since 1 July 2008, as a result of breast cancer.

Download and complete the Claim for External Breast Prostheses Reimbursement Program form.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.

Page last updated: 13 December 2023.
QC 20331