Québec's Ministère de l'Emploi et de la Solidarité sociale uses the SR-0040 Certificat médical for people receiving last-resort financial assistance. It certifies a pregnancy and the need for prenatal or postnatal medical transport, and it supports requests for special benefits for medical needs such as prostheses, orthopedic shoes, oxygen, home hemodialysis, a health-related move or medical transport. The ministry keeps the original and gives the recipient a photocopy.
A physician, specialized nurse practitioner (IPS) or midwife certifies pregnancy and prenatal or postnatal transport, while a physician, dentist or IPS requests medical special benefits; they complete Sections 3 to 6 and sign with their licence number. The recipient signs the Section 2 authorization, printed in French and English.
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It depends on the section. A physician, specialized nurse practitioner or midwife can attest a pregnancy and the need for prenatal or postnatal medical transport. A physician, dentist or specialized nurse practitioner can request special benefits for medical needs. The professional signs Section 6 and adds their licence number.
The form is published in French. Only the recipient's authorization in Section 2 is bilingual; it lets the consulted health professional give the ministry any information about the recipient's current or past physical or mental health.
Section 3 asks for the current number of weeks of pregnancy, the expected date of delivery and any remarks. Medical transport needs, such as travel for prenatal or postnatal follow-up, go in Section 5 with the medical reason, frequency and duration.