Prescribers practising outside Québec use this one-page request when a Québec-insured patient needs RAMQ to pay for an exception drug listed in Annex IV of the Liste des médicaments. It mirrors form 3633, which Québec prescribers have largely replaced with RAMQ's online service. RAMQ reviews the justification against the drug's recognized indications for payment and mails its decision.
The out-of-Québec prescriber completes the whole page: the patient's Québec health insurance number and details, prescriber details, the drug requested, the justification and diagnosis, then signs and dates it. The bottom box is for RAMQ's use only.
Download the current version from the source each time; forms change without notice.
Demande d'autorisation de paiement (hors Québec) – Médicament d'exception
Request for Payment Authorization (Outside Québec) – Exception Drug
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.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Physicians and other prescribers practising outside Québec who have not joined Québec's health insurance plan. Their patient must be insured by RAMQ, and the form asks for the patient's Québec health insurance number, a temporary number from the claim booklet, or a parent's number for a child under one year old.
RAMQ publishes form 4515 in French only. It has four numbered parts: Personne assurée, Prescripteur autorisé, Médicament visé par la demande and Justification de la demande, followed by the diagnosis and the prescriber's signature. A final box records RAMQ's authorized payment period and maximum quantity.
By mail. RAMQ sends out-of-Québec prescribers its decision, or a request for more information, by post. RAMQ's service statement targets 25 business days for a complete exception-drug request and 1 business day for a complete priority request, so attaching every supporting document up front avoids delays.