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1
CHECK THE
APPROPRIATE BOX
FOR OFFICE USE
LETTERS NUMBERS
IDENTITY OF INSURED PERSON
HEALTH INSURANCE NUMBER
APPLICATION FOR REIMBURSEMENT
Health-care services received:
in Canada outside Canada
(the person who received the services)
INSURED PERSON'S LAST NAME
FIRST NAME
MF
INSURED PERSON'S LAST NAME
(AS APPEARING ON HEALTH INSURANCE CARD)
DATE OF BIRTH SEX
YEAR MONTH DAY
••• • •
TELEPHONE NUMBER AT HOME TELEPHONE NUMBER AT WORK
PROVINCE POSTAL CODE AREA CODE AREA CODE
NO. STREET APT. CITY OR LOCALITY
ADDRESS OF PERMANENT RESIDENCE IN QUÉBEC
ADDRESS OUTSIDE QUÉBEC
NO. STREET APT. CITY OR LOCALITY
TELEPHONE NUMBER AT HOME TELEPHONE NUMBER AT WORK
PROVINCE OR STATE AND COUNTRY POSTAL CODE AREA CODE AREA CODE
ADDRESS
ADDRESS
ADDRESS
REIMBURSEMENT CHEQUE
TO BE MAILED TO:
INQUIRIES TO BE SENT TO:
ADDRESS
Date of departure
from Québec
YEAR MONTH DAY
Date of return to Québec
PERIODS OF TIME SPENT OUTSIDE QUÉBEC
Period during which you received health-care services
YEAR MONTH DAY
ACTUAL
DATE
PLANNED
DATE
vacation or seasonal absence
Employer's name:
.................................................................................................................................................................................................
work
studies
other
Within Canada
permanent move
DATE OF
MOVE
.................................................................................................................................................................................
Specify
YEAR MONTH DAY
to receive
health care not
available in Québec
Outside
Canada
Attach a written attestation from the educational institution showing the dates
of the beginning and end of your courses, unless you have already done so.
Number of the Régie's authorization . .......................................................
REASON FOR SPENDING TIME OUTSIDE QUÉBEC (CHECK ONE REASON ONLY)
3rd PERIOD
YEAR MONTH DAY
2nd PERIOD
YEAR MONTH DAY
DATE OF DEPARTURE DATE OF RETURN
1st PERIOD
YEAR MONTH DAY YEAR MONTH DAY
YEAR MONTH DAY
If you spent other periods of more than 21 consecu-
tive days outside Québec during the calendar year
(Jan. 1 to Dec. 31), please specify:
YEAR MONTH DAY
DATE OF DEPARTURE DATE OF RETURN
DATE OF DEPARTURE DATE OF RETURN
Give the reason for which you received health-care services
HEALTH-CARE SERVICES RECEIVED
IN THE CASE OF AN ACCIDENT, SPECIFY THE TYPE OF ACCIDENT
AUTOMOBILE WORK OTHER (specify)
Describe the services received (examinations, x-rays, surgery, etc.). If you need more space, use a separate sheet.
CANADIAN PROVINCE OR U.S. STATE
COUNTRY
IF YOU WERE HOSPITALIZED,
SPECIFY THE
NUMBER
OF DAYS:
WHERE DID YOU RECEIVE THE SERVICES?
DATE OF
ACCIDENT
YEAR MONTH DAY
REIMBURSEMENT
AMOUNT CLAIMED
CANADIAN
CURRENCY
FOREIGN
CURRENCY
SUPPORTING DOCUMENTS
Have you paid the bills?
NO YES
If you did not have travel insurance when you received the services, send all required documents to the Régie.
If you did have travel insurance when you received the services, check whether your insurance company will
apply to the Régie for a reimbursement on your behalf.
AMOUNT PAID
(enclose originals of receipts)
If yes, send all required documents to the insurance company.
If no, send all required documents to the Régie.
NAME OF INSURANCE COMPANY POLICY NUMBER
SPECIFY:
IN FULL IN PART
1896
266 02/04
SIGNATURE AND AUTHORIZATION
MONTH DAY
YEAR
RELATIONSHIP TO INSURED PERSON
(FATHER, MOTHER, SPOUSE, GUARDIAN , ETC.)
FRENCH
ENGLISH
LANGUAGE OF
CORRESPONDENCE
NAME OF PERSON SIGNING THIS FORM, IF OTHER THAN
THE INSURED PERSON
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 institution any additional information that it may
require, and I understand that I must pay the cost of any fees the Régie may
incur in obtaining this information.
If my application results from an automobile accident or a work accident, to
simplify the processing of my application I authorize the Régie to provide
the SAAQ or the CSST with a copy of any documents I may send to or
receive from the Régie.
Before completing this form, refer to the Régie's
pamphlet entitled
Health-Care Services Insured
Outside Québec
.
SIGNATURE
CITY OR LOCALITY
