Fillable Nursing Care Questionnaire - Group Insurance Form printable pdf download

GROUP INSURANCE

Quebec

Ontario, Atlantic and Western Provinces

Group Health and Dental Claims

NURSING CARE

PO Box 800, Station Maison de la Poste

PO Box 4643, Station A

Montreal, Quebec H3B 3K6

Toronto, Ontario M5W 5E3

QUESTIONNAIRE

INSTRUCTIONS

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

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 nursing care benefit, please have the patient’s attending physician provide

the information requested in the “TO BE COMPLETED BY THE ATTENDING PHYSICIAN” section.

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. 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 nursing 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 eligibility for the

nursing care benefit.

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

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

Plan member signature

Date signed

_________________________________________________________________________________________________________________

TO BE COMPLETED BY THE ATTENDING PHYSICIAN

(PLEASE PRINT CLEARLY)

3. PATIENT CLINICAL INFORMATION

Please provide a brief summary of the patient’s condition/diagnosis requiring nursing care ______________________________________________________________

_______________________________________________________________________________________________________________________________________________

Prognosis _____________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

Amount of care required: Hours per day __________ Days per week __________

Expected duration of care: From

Level of care required: RN

RNA

Other

If other, please specify _____________________________________________________________________

Location where services will be provided: Home

Hospital

Other