Pharmacies use this one-page transmittal slip to claim reimbursement from IVAC, Quebec's crime victims compensation program, for prophylactic medication dispensed to a victim. It serves as the fax cover for the claim, identifying the pharmacy and its IVAC supplier number and listing the documents attached. The prescriber's prophylaxis prescription and a copy of the health evaluation travel with it.
The pharmacist completes the pharmacy identification, IVAC supplier number, attached-document checklist and comments, and the claimant signs the slip.
Download the current version from the source each time; forms change without notice.
Bordereau de transmission – Frais de médicaments prophylactiques
Transmittal Slip – Prophylactic Medication Costs (IVAC)
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Fax form 1904, the Bordereau de transmission for prophylactic medication costs, with the pharmacy invoice, a copy of the victim's health evaluation and the prescriber's prophylactic medication prescription. Add the victim's IVAC qualification request if you have it. The slip identifies the pharmacy, gives its IVAC supplier number and lists what is attached.
The pharmacy completes its identification, IVAC supplier number, document checklist and comments, and the claimant signs the slip. The prescription itself comes from the prescriber who ordered the prophylaxis, and the health evaluation from the professional who assessed the victim.
No. IVAC's forms, including this Bordereau de transmission for prophylactic medication costs, are published in French only. The current version, dated 2022-08, is a fillable PDF that can be completed on screen, printed for the claimant's signature and faxed to IVAC with the supporting documents.