Document to be completed by your rheumatologist (applicable fees)

If you have an insurance document to be filled-out by your doctor (disability for example) or a government form (SAAQ or Quebec Pension Board) please follow this procedure:

  • Be sure that the identification and authorization parts are filled-out with your name, contract number, RAMQ number or social insurance number, and date of birth. It is important that the authorisation section is signed. If some information is missing it can create a delay in the processing of your claim.

 

  • You can send us your form by:

        -Mail or in person: C/O “name of your doctor”, 1551 Ontario Est, Montreal, Quebec, H2L 1S6.

        -By Fax (if accepted by your supplier): 514-523-5973.

  • Please indicate who we need to send the completed form to: insurance company, agent, employer, etc. with their contact information.

  • Please note that if you give your form to your rheumatologist on the day of your appointment, it is possible that he can not fill it out during your visit.  It will be done later and sent when it’s ready.

1551, rue Ontario Est
Montréal (Québec)  H2L 1S6

 

Pour toute urgence, composez le 911

© 2016 Institut de Rhumatologie de Montréal

révision Septembre 2018.

L'IRM remercie Abbvie, Amgen, Lilly, Merck, Novartis, Pfizer, Roche, Sanofi et UCB pour leur support.

Une réalisation