All the informaon I have provided on the claim form is accurate and complete. I acknowledge having read the Personal Informaon Management secon. I authorize Desjardins Insurance strictly
for the purposes of managing my le and seling this claim to: (a) collect from any person or legal enty, or from any public or parapublic organizaon, only the informaon deemed necessary
to manage my le. The non-exhausve list of sources from which informaon may be collected includes healthcare professionals or facilies, insurance companies; (b) communicate to the said
persons or organizaons only the personal informaon about me that is deemed necessary for the purposes of my le; (c) when necessary use the personal informaon it may have about me in
exisng les that are now closed.This authorizaon is also valid for the collecon, use and communicaon of personal informaon concerning my dependents, insofar as applicable to the claim.
A photocopy of this authorizaon is as valid as the original.
Signature of member
Date
Page 1 of 298130E (2020-02)
Date of event
No., street, apartment
Postal code
City Province
Policy or group or contract No.
Cercate No.
Address
Last name and rst name of member
Date of birth
Name of the person for whom expenses were incurred Relaonship to member Date of birth
Name of group or policyholder or employer Signature of administrator (if required)
Date
Sex
M
F
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
1. Type of event (check the corresponding event(s))
Hospitalizaon
Surgery
2. Describe the circumstances that led to the hospitalizaon, surgery or accident:
3. Are the claimed benets covered under another insurance contract?
Yes No
If yes: Name of insurer: Contract No.:
4. Was Assistel contacted before services were received?
Yes No If yes, le No.:
IMPORTANT: IF YOUR RETURN TO WORK IS ANTICIPATED, PLEASE ADVISE THE INSURER ON THE RETURN DATE.
Desjardins Financial Security Life Assurance Company, hereinaer Desjardins Insurance, handles the personal informaon it has on you in a condenal manner. Desjardins Insurance keeps this
informaon on le so that you may benet from group insurance services oered by the Company. This informaon is consulted solely by Desjardins Insurance employees who need to do so in the
course of their work. Desjardins Insurance may compile anonymized personal informaon for stascal and informaonal purposes. Desjardins Insurance may also communicate with plan members
to provide them with opmal health management. You have the right to consult your le. You may also have informaon corrected if you demonstrate that it is inaccurate, incomplete, ambiguous
or not useful. To do so, you must send a wrien request to the following address: Privacy Ocer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance
may use the client list to oer its clients an insurance product following the terminaon of their group insurance. If you do not wish to receive these oers, you may have your name removed from
the list. To do so, you must send a wrien request to the Privacy Ocer at Desjardins Insurance.
Telephone Nos.: Home: Oce: Extension:
1. Diagnosis:
2. Treatment or type of surgery:
3. Hospitalizaon: Admission date: Discharge date:
Name of hospital:
4. Check the loss of autonomy criteria jusfying a period of convalescence:
Eang - The insured person needs assistance in preparing meals or feeding himself.
Moving - The insured person needs assistance in geng out of a bed or a chair, lying down or sing.
Dressing - The insured person needs assistance in pung on or taking o his clothes and his orthopedic prosthesis.
Taking care of basic hygiene needs - The insured person needs assistance in washing, geng in or out of the bathtub or shower or using the toilet.
5. Period of prescribed convalescence: period during which the insured person must necessarily present one or more loss of autonomy criteria listed above:
From To Number of days:
6. Did you recommend home nursing care? Yes No If yes, for which type of services?
7. Did the insured person previously consult you or another professional for the condion requiring hospitalizaon or sugery before ? Yes No
If yes, please provide the following informaon:
Name of aending physician Date of visits Diagnosis Treatments
8. Was the convalescence prescribed following a delivery? Yes No
If yes, was the insured person hospitalized at your recommendaon for more than seven (7) days aer delivery due to complicaons?
Yes No If yes, please indicate the:
a) Number of days in hospital (aer delivery): days
b) Details of complicaons :
YYYY MM DD
YYYY MM DD
YYYY MM DD YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
Licence No.:
Telephone No.:
Signature of aending physician: Date:
YYYY MM DD
Group Insurance - Health Claims
CLAIM – CONVALESCENT CARE
A GENERAL INFORMATION
– TO BE COMPLETED BY THE MEMBER.
B PERSONAL INFORMATION MANAGEMENT
C DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
D CONVALESCENCE PERIOD
– TO BE COMPLETED BY THE ATTENDING PHYSICIAN WHO PRESCRIBED THE CONVALESCENCE.
Name and address of the aending physician (PLEASE PRINT)
Desjardins Insurance, life, health, rerement logo
Address C. P. 3950 Lévis Québec G 6 V 9 X 8 web site desjardins life insurance dot com slash plan member Telephone 1 8 0 0 2 6 3 1 8 1 0
