Before completing this form, read the reverse
side and refer to the information on our website
at www.ramq.gouv.qc.ca. Click on Temporary
stays outside Québec under Citizens.
APPLICATION FOR REIMBURSEMENT
CHECK THE
APPROPRIATE BOX
Healthcare services received :
in Canada outside Canada
FOR OFFICE USE
Automobile Work Other (specify)
Describe the services received (examinations, x-rays, surgery, etc.). If you need more space, use a separate sheet.
Year Month Day
IN THE CASE OF AN ACCIDENT, SPECIFY THE TYPE OF ACCIDENT
Give the reason for which you received these healthcare services
Date of accident
MUNICIPALITY CANADIAN PROVINCE OR U.S. STATE COUNTRY
If applicable,
indicate the number of days
you were hospitalized:
WHERE DID YOU RECEIVE THESE SERVICES?
HEALTHCARE SERVICES RECEIVED
In full In part No Ye s
Amount claimed
AMOUNT PAID
(enclose originals of receipts)
Have you paid the bills?
Canadian
dollars
Other
currency
SPECIFY:
REIMBURSEMENT
1896 266 16/09
No Ye s
Were you covered by travel insurance when you received the services?
POLICY NUMBERNAME OF INSURANCE COMPANY
TRAVEL INSURANCE
SIGNATURE
MONTH DAYYEAR
X
I hereby declare, knowing that this declaration has the same value as though it were made under oath in accordance with the Canada Evidence Act, that the above information is accurate. I authorize the Régie to request from the
health professional or facility any additional information that it may require. If this information is not provided free of charge, I agree to it being obtained at my expense.
If my application results from an automobile accident or a work accident, I authorize the RAMQ to provide the SAAQ or the CNESST with a copy of any documents I may sent to or receive from the Régie.
NAME OF PERSON SIGNING THIS FORM, IF OTHER THAN THE APPLICANT RELATIONSHIP TO APPLICANT
(FATHER, MOTHER, SPOUSE, GUARDIAN ETC.)
SIGNATURE AND AUTHORIZATION
APPLICANT'S IDENTITY
DATE OF BIRTH
YEAR MONTH DAY
LAST NAME AT BIRTH
(IF DIFFERENT FROM THE NAME ON THE HEALTH INSURANCE CARD)
LAST NAME
FIRST NAME
HEALTH INSURANCE NUMBER
LETTERS NUMBERS
NO. STREET APT
. MUNICIPALITY
HOME ADDRESS (see over)
SEX
M F
AREA CODE AREA CODE
PHONE NUMBER AT HOME PHONE NUMBER AT WORKPOSTAL CODEPROVINCE
1st PERIOD
2nd PERIOD
3rd PERIOD
Vacation or seasonal absence
Work
Studies
Receipt of healthcare not
available in Québec
Other
Date of move
ACTUEL PLANNED
DATE DATE
REASON FOR SPENDING TIME OUTSIDE QUÉBEC (CHECK ONE BOX ONLY)
Year Month Day Year
Year
Month
Month
Day
Day
If you spent other periods of more than 21 consecutive days outside Québec
during the calendar year (January 1 to December 31), please specify:
Date of return
Date of return
Date of return
Date of departure
Date of departure
Date of departure
Period during which you received healthcare services
Date of departure from Québec
Régie's authorization number
Specify
Employer's name
Attach a written attestation from the educational institution showing the
beginning and end dates of your courses, unless you have already done so.
Date of return to Québec
PERIODS OF TIME SPENT OUTSIDE QUÉBEC
Year
Year
Year
Year
Year
Year
Month
Month
Month
Month
Month
Month
Day
Day
Day
Day
Day
Day
Permanent move outside Québec
I hereby authorize the Régie de l’assurance maladie du Québec to provide to and receive from my travel insurance company all the information and documents required for the assessment and payment of
my claims for insured medical and hospital services that I received and, if applicable, that my spouse or children received (family insurance).
