Fillable Home Care Questionnaire printable pdf download

group insurance

Quebec

Ontario, Atlantic and Western Provinces

Group Health and Dental Claims

PO Box 800, Station Maison de

PO Box 4643, Station A

CLAIM REQUEST

la Poste

Toronto, Ontario M5W 5E3

HOME CARE QUESTIONNAIRE

Montreal, Quebec H3B 3K6

INSTRUCTIONS

1. The details requested below are required in order for Industrial Alliance to determine the eligibility of your request for reimbursement under the home care

benefit. For prior approval, please forward this form to the address indicated above. You will then receive a confirmation letter from Industrial Alliance

concerning your request once the review has been completed.

2. In order to determine the eligibility of your request for reimbursement under the home care benefit, please have the patient’s attending physician provide

the information requested in the “TO BE COMPLETED BY THE ATTENDING PHYSICIAN” section which is on the reverse side of this form.

Note: Some financial assistance programs exist for home care services. We invite you to contact your Local Community Services Center (CLSC)

TO BE COMPLETED BY THE PLAN MEMBER

(PLEASE PRINT CLEARLY)

1. PLAN MEMBER INfORMATION

Policy no.

Certificate no.

Plan member’s name

_____________________________________________________________________________________________________________________________________________________________________

Patient’s name

Date of birth

___________________________________________________________________________________________________________________________

Relationship to the plan member

_______________________________________________________________________________________________________________________________________________________

2. COORDINATION Of BENEfITS

Are these fees covered by another insurance plan?

Yes

If yes, please provide the name of the policyholder

__________________________________________________________________________________________________________________________________

Name of the other insurance company

Contract Number ________________________________

____________________________________________________________________________

Protection:

Family

Single parent

Individual

Couple

3. NATURE Of fEES

Are the fees to be incurred for home care services related to a work accident?

Yes

Are the fees to be incurred for home care services related to a car accident?

Yes

4. TRANSPORTATION fEES

During your recovery at home, will you need to travel to receive medical care or medical follow-up?

Yes

Which doctor(s) will you need to consult? _________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

Indicate the dates of the consultations

Note: Please provide a medical certificate from your doctor for each consultation and indicate the dates of the hospitalization period or the date of

the day surgery. Fees are only reimbursed upon presentation of receipts (ex. gasoline, bus, parking).

5. CHILD CARE fEES

During your recovery, will you incur child care fees that are in excess of those usually incurred?

Yes

Note: Please provide receipts clearly indicating the name of the child care services provider, including the address and telephone number.

6. PLAN MEMBER CONfIRMATION / AUTHORIZATION

If this questionnaire is being submitted in respect to my spouse or dependent child, I CONFIRM that I am AUTHORIZED to disclose information about him/her

in regards to the home care services to be or being received.

I AUTHORIZE any healthcare provider or professional, medical organization, insurance or reinsurance company, workers’ compensation board, the policyholder, my

employer, as well as any other person, public or private organization or institution to disclose to Industrial Alliance, its employees, agents and any service providers

any information which they may need in the assessment of the information contained in this questionnaire in order to determine the eligibility for the home care benefit.

I AUTHORIZE the use of my Social Insurance Number as an identification number where required for administration of the group policy.

I AGREE that a photocopy of this Confirmation/Authorization shall be as valid as the original.

Patient’s name

Date signed

__________________________________________________________________________________________________________________________

Please have the attending physician complete and sign the reverse side of this form.

F54-896A