Fillable REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED (Desjardins Insurace)

Fill Online, Printable, Fillable, Blank REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED (Desjardins Insurace) Form

Use Fill to complete blank online DESJARDINS INSURACE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED (Desjardins Insurace)

On average this form takes 4 minutes to complete

The REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED (Desjardins Insurace) form is 1 page long and contains:

  • 0 signatures
  • 4 check-boxes
  • 15 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Desjardins Insurace forms online.

BROWSE DESJARDINS INSURACE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
13175E (2020-02)
REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED IN THE DYNAMIC
THERAPEUTIC FORMULARY (DTF) OR OF A BRAND NAME MEDICATION
PLEASE HAVE YOUR ATTENDING PHYSICIAN FILL OUT THE BACK OF THIS FORM.
Desjardins Insurance life health rerement logo
M
F
M
F
YYYY MM DD
YYYY MM DD
Name of policyholder Group no. Cercate no.
Last name and rst name of member Sex Date of birth
Address - No., street, apt. City Province Postal code
Last name and rst name of paent Sex Date of birth
Relaonship to member DIN (Drug Idencaon Number)
All the informaon I have provided on the claim form is accurate and complete. I acknowledge having read the Personal Informaon Management secon. I authorize
Desjardins Insurance strictly for the purposes of managing my le and seling this claim to: (a) collect from any person or legal enty, or from any public or parapublic
organizaon, only the informaon deemed necessary to manage my le. The non-exhausve list of sources from which informaon may be collected includes healthcare
professionals or facilies, insurance companies; (b) communicate to the said persons or organizaons only the personal informaon about me that is deemed necessary
for the purposes of my le; (c) when necessary, use the personal informaon it may have about me in exisng les that are now closed. This authorizaon is also valid for
the collecon, use and communicaon of personal informaon concerning my dependents, insofar as applicable to the claim. A photocopy of this authorizaon is as valid
as the original.
Signature of member
Date
Signature of insured
dependent aged 16 and over: Date:
Desjardins Financial Security Life Assurance Company, hereinaer Desjardins Insurance, handles the personal informaon it has on you in a condenal manner. Desjardins
Insurance keeps this informaon on le so that you may benet from group insurance services oered by the Company. This informaon is consulted solely by Desjardins
Insurance employees who need to do so in the course of their work. Desjardins Insurance may compile anonymized personal informaon for stascal and informaonal
purposes. Desjardins Insurance may also communicate with plan members to provide them with opmal health management. You have the right to consult your le. You may
also have informaon corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a wrien request to the following address:
Privacy Ocer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance may use the client list to oer its clients an insurance product
following the terminaon of their group insurance. If you do not wish to receive these oers, you may have your name removed from the list. To do so, you must send a wrien
request to the Privacy Ocer at Desjardins Insurance.
Group Insurance - Health Claims
• Any charges for the compleon of this form are the member’s responsibility.
• The member must complete secons A and C.
• If the request is for the reimbursement of a medicaon that is not included in the DTF, the aending physician must complete secons D and F. If the request is for the
reimbursement of a brand name medicaon, the aending physician must complete secons E and F. The member must have read and understood the instrucons
provided in these secons.
• This request will be assessed based on the medical informaon provided and may be reviewed by our physician or pharmacist.
IMPORTANT INFORMATION
A PATIENT'S IDENTIFICATION - To be completed by the member.
B PERSONAL INFORMATION MANAGEMENT
C DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
Address C. P. 3950 Lévis Québec G 6 V 8 C 6 web site desjardins life insurance dot com slash plan member Telephone 1 8 0 0 2 6 3 1 8 1 0
C. P. 3950
Lévis (Québec) G6V 8C6
desjardinslifeinsurance.com/planmember
Tel.: 1-800-263-1810
Fax: 418-838-2134 or 1-877-838-2134
PRINT
NEW REQUEST
Please send form by fax: 418-838-2134 or 1-877-838-2134
or by mail: Desjardins Insurance, C. P. 3950, Lévis (Québec) G6V 8C6
Please send form by fax: 4 1 8 8 3 8 2 1 3 4 toll free: 1 8 7 7 8 3 8 2 1 3 4 or by mail: Desjardins Insurance CP 3950 Lévis Québec G 6 V 8 C 6
• The medicaon for which you are applying for an excepon is not included in the DTF and is currently covered at a lower percentage. If this excepon is approved, the
medicaon will be covered at a higher percentage.
• The excepon will only be approved if the physician provides an acceptable medical reason to support why the paent is unable to take a therapeuc alternave listed
in the DTF.
• The approved medicaon will be covered up to the lowest cost generic equivalent available on the market. If the paent cannot take the generic equivalent either,
another acceptable medical reason will need to be provided in secon E.
E BRAND NAME MEDICATION
DECLARATION OF ATTENDING PHYSICIAN - To be completed by the physician.
• The brand name medicaon for which you are applying for an excepon is currently covered up to the lowest cost generic equivalent available on the market. If this
excepon is approved, the medicaon will be covered at the price provided for the brand name medicaon.
• The excepon will only be approved if the aending physician provides an acceptable medical reason to support why the paent is unable to take the lowest cost
generic equivalent available on the market.
1. What is the paent's diagnosis?
2. Brand name drug requested:
Name and strength: DIN:
Dosage:
3. Generic drug tried:
Name and strength: DIN:
Dosage: Treatment period: From To
4. What is the medical reason for the request: Allergies Adverse reacon Therapeuc failure Other:
The eects aributable to the adverse or allergic reacon are:
Mild (no intervenon required) Moderate (minimal intervenon required) Severe (hospitalizaon required) Life threatening
Please describe the adverse or allergic reacon observed (nature, extent, severity):
1. What is the paent's diagnosis?
2. Drug requested:
Name and strength: DIN:
Dosage:
3. Alternave drug listed on the DTF tried:
Name and strength: DIN:
Dosage: Treatment period: From To
4. What is the medical reason for the request: Allergies Adverse reacon Therapeuc failure Other:
The eects aributable to the adverse or allergic reacon are:
Mild (no intervenon required) Moderate (minimal intervenon required) Severe (hospitalizaon required) Life threatening
Please describe the adverse or allergic reacon observed (nature, extent, severity):
D MEDICATION NOT INCLUDED IN THE DYNAMIC THERAPEUTIC FORMULARY (DTF)
DECLARATION OF ATTENDING PHYSICIAN - To be completed by the physician.
( ) -
( ) -
Last name and rst name of physician (PLEASE PRINT)
Address - No., street, suite City Province Postal code
Telephone no.: Fax no.:
Signature of physician: Date:
F PHYSICIAN'S IDENTIFICATION - To be completed by the physician.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED (Desjardins Insurace)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document