12126E (2020-02)
Group Insurance - Health Claims
REQUEST FOR REIMBURSEMENT
OF BRAND NAME MEDICATIONS
• Any charges for the compleon of this form are the member's responsibility.
• The brand name medicaon for which you are applying for an excepon is currently covered up to the lowest cost generic equivalent available on the market. If this
excepon is approved, the medicaon will be covered at the price provided for the brand name medicaon.
• Please complete secons A and B and have your physician complete secons C and D. The excepon will only be approved if the physician provides an acceptable
medical reason to support why the paent is unable to take the lowest cost generic equivalent available on the market. This request will be assessed based on the
medical informaon provided and may be reviewed by our physician or pharmacist.
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
Desjardins Insurance life health rerement logo
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 C P 3950 Lévis Québec G 6 V 8 C 6
Name of policyholder Group no. Cercate 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 paent Sex Date of birth
Relaonship to member DIN (Drug Idencaon Number)
M
F
M
F
YYYY MM DD
YYYY MM DD
1. What is the paent'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 reacon Therapeuc failure Other:
The eects aributable to the adverse or allergic reacon are:
Mild (no intervenon required) Moderate (minimal intervenon required) Severe (hospitalizaon required) Life threatening
Please describe the adverse or allergic reacon observed (nature, extent, severity):
C - PHYSICIAN'S STATEMENT - To be completed by 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:
D - PHYSICIAN'S IDENTIFICATION - To be completed by physician.
All the informaon I have provided on the claim form is accurate and complete. I acknowledge having read the Personal Informaon Management secon at the back of
the form. I authorize Desjardins Financial Security Life Assurance Company (DFS), hereinaer 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
Signature of insured dependent aged 16 and over: Date:
B - DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
A - PATIENT'S IDENTIFICATION - To be completed by the member.
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
