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FOR PHYSICAL ILLNESSES INITIAL ATTENDING PHYSICIANS STATEMENT 2. (Desjardins Insurace)

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02025A (2018-09)
Informaon about your diagnosis should be provided by your aending physician. Therefore this secon is non llable online.
Desjardins Insurance life health rerement logo
To submit by fax: 4 1 8 8 3 5 0 1 9 4 or toll free 1 8 4 4 4 0 9 6 5 7 5 Keep original forms for your records.
Submit online:
desjardinslifeinsurance.com/send
Complete and save the form on your computer rst.
Keep original forms for your record
s.
By mail:
C. P. 3875 succ. Lévis
Lévis (Québec) G6V 0A7
Send original forms and keep copies
for your records.
By fax:
1-844-409-6575 (toll free)
418-835-0194
Keep original forms for your records.
INITIAL ATTENDING PHYSICIAN’S STATEMENT
FOR PHYSICAL ILLNESSES
To submit by mail: CP 3875 succursale Lévis Lévis Québec G 6 V 0 A 7. Send original forms and keep copies for your records.
To submit online. Complete and save the form on your computer first. Keep original forms for your records.
Note: For psychological illnesses, complete the form on the reverse.
4.1 Date of rst consultaon for this disability: Next consultaon:
4.2 Dates of other consultaons: Follow-up frequency:
4.3 Referral to another physician: No Yes Name of physician:
Specialty:
4.4 Approximate duraon of disability: No. of days: No. of weeks: Unspecied or date of return to work:
4.5 How long before the paent will be able to return to work? No. of days: No. of weeks:
Part-me Full-me Gradual return Specify:
3.1 Drugs – name – dosage:
3.2 Has the paent undergone or will undergo:
a) examinaons or tests No Yes Specify:
b) surgery No Yes Day surgery Type: Date:
Surgical procedure:
c) other treatments No Yes Specify:
d) hospitalizaon: From To Name of hospital:
e) a short stay under observaon No Yes Number of hours:
3. Treatment
2.1 Principal: 2.2 Secondary:
2.3 Complicaons:
2.4 For the illnesses or associated symptoms diagnosed, has the paent previously:
received medical treatments consulted another physician taken drugs been hospitalized undergone examinaons
Specify the periods:
2.5 Is the disability related to: An accident An illness
An occupaonal accident An automobile accident
A pregnancy A prevenve withdrawal from work
2.6 Describe funconal limitaons that prevent the paent from carrying out professional dues or usual acvies.
At the beginning of disability: :
Currently:
2. Diagnosis - Complete in block leers and give to the employee.
Date of the event:
Scheduled date of delivery:
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD YYYY MM DD
4. Follow-up and prognosis
YYYY MM DD
YYYY MM DD
5. Addional informaon - Please use a separate sheet if necessary.
( )
( )
6.1 Family name, given name: Telephone: Fax:
6.2 License number: General praconer Specialist Specify:
Signature: Date:
6. Idencaon of the physician
NOTE: THE EMPLOYEE MUST PAY THE FEES REQUESTED TO COMPLETE THIS FORM.
Last name and rst name Policy or group or contract no. Cercate or idencaon no. Date of birth
1. Idencaon of the employee - This secon must be completed by the employee.
YYYY MM DD
Fédéraon des médecins omnipraciens du Québec logo
Regroupement des assureurs de personnes à charte du Québec logo
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NEW REQUEST
Note: For physical illnesses, complete the form on the reverse.
Informaon about your diagnosis should be provided by your aending physician. Therefore this secon is non llable online
2.1 Principal:
2.2 Secondary:
2.3 Current symptoms:
2.4 Degree of severity of all symptoms: Mild Moderate Severe With psychoc elements
2.5 Does the interrupon of work result from problems related to:
Marital/family life Loss of employment or layo Professional problems
Personal or interpersonal problems Alcohol or drug abuse or gambling problems
Other problems, specify:
2.6 For the illnesses or associated symptoms diagnosed, has the paent previously:
received medical treatments consulted another physician taken drugs been hospitalized undergone examinaons
Specify the dates of previous episodes:
4.1 Date of rst consultaon for this disability: Next consultaon:
4.2 Dates of other consultaons:
4.3 Follow-up frequency:
4.4 Will the paent be referred to a psychiatrist? No Yes Name of physician:
4.5 Approximate duraon of disability: No. of days: No. of weeks: Unspecied or date of return to work:
4.6 How long before the paent will be able to return to work? No. of days: No. of weeks:
Part-me Full-me Gradual return Specify:
6.1 Family name, given name: Telephone: Fax:
6.2 License number: General praconer Specialist Specify:
Signature: Date:
( )
( )
3.1 Drugs – name – dosage:
3.2 Is the paent consulng: a psychiatrist a psychologist a social worker another health care provider
If yes, name of the caregiver consulted:
3.3 Hospitalizaon: From: To: Name of hospital:
2. Diagnosis - Complete in block leers and give to the employee.
3. Treatment
YYYY MM DD YYYY MM DD
4. Follow-up and prognosis
YYYY MM DD YYYY MM DD
5. Addional informaon - Please use a separate sheet if necessary.
6. Idencaon of the physician
NOTE: THE EMPLOYEE MUST PAY THE FEES REQUESTED TO COMPLETE THIS FORM.
Last name and rst name Policy or group or contract no. Cercate or idencaon no. Date of birth
1. Idencaon of the employee - This secon must be completed by the employee.
YYYY MM DD
INITIAL ATTENDING PHYSICIAN’S STATEMENT
FOR PSYCHOLOGICAL ILLNESSES
Submit online:
desjardinslifeinsurance.com/send
Complete and save the form on your computer rst.
Keep original forms for your record
s.
By mail:
C. P. 3875 succ. Lévis
Lévis (Québec) G6V 0A7
Send original forms and keep copies
for your records.
By fax:
1-844-409-6575 (toll free)
418-835-0194
Keep original forms for your records.
Desjardins Insurance life health rerement logo
Fédéraon des médecins omnipraciens du Québec logo
Regroupement des assureurs de personnes à charte du Québec logo
To submit by fax: 4 1 8 8 3 5 0 1 9 4 or toll free 1 8 4 4 4 0 9 6 5 7 5 Keep original forms for your records.
To submit by mail: CP 3875 succursale Lévis Lévis Québec G 6 V 0 A 7. Send original forms and keep copies for your records.
To submit online. Complete and save the form on your computer first. Keep original forms for your records.
PRINT
NEW REQUEST
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FOR PHYSICAL ILLNESSES INITIAL ATTENDING PHYSICIANS STATEMENT 2. (Desjardins Insurace)

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Completed 9 February 2021

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