Québec physicians who will perform the procedures themselves use this four-page French form to ask RAMQ to authorize plastic surgery as an insured service. It lists scar correction, breast procedures, lipectomies, eyelid surgery, gynecomastia, varicose vein excision, fat injection, tissue expanders, facial reanimation and laser treatments. Initial requests need colour photos, and a request without the functional limitations section is incomplete and is not analyzed.
The requesting physician completes all seven sections: insured person, provider, procedures requested, functional limitations, previous procedures and relevant history, comments, and signature with date. The form is meant for physicians with the skills to perform the requested procedures themselves.
Download the current version from the source each time; forms change without notice.
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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Colour photos that adequately show the problem to be treated must accompany every initial request, for each procedure. The only exception is excision of varicose veins of the lower limbs, for which no photo is required and the consultation report is enough.
Yes. The form suggests attaching mammography or ultrasound reports for gynecomastia and interpreted peripheral visual fields for eyelid surgery. Previous relevant procedures, with dates and whether RAMQ insured them, and relevant medical history go in Section 5.
No. RAMQ posts it in French only as Demande d'autorisation en plastie, version 4248 235 25/04. Its fourth page contains completion instructions, including the requirement that the physician sign and date the request and attach all supporting documents.