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Blue Cross Québec Critical Illness Claim: 01QRM0084A

Blue Cross Canassurance requires this package when an insured person claims a critical illness benefit, and it must reach the insurer within 90 days of the diagnosis. It combines the claimant's statement, an attending physician statement with ICD-9 coded diagnoses, medical certificates for out-patient treatment and home nursing care, and three authorizations. The claimant forwards the completed package to the address for their province of residence.

Who completes it

The physician completes the Attending Physician Statement (01QRM0084A) and gives it to the patient, who fills in only the identification section. The clinic completes the out-patient treatment certificate, the doctor who prescribed home nursing completes that certificate, and the claimant completes the Claimant's Statement and signs all three authorizations.

Submitting and payment

How to submit it
The claimant sends the whole package to Blue Cross Canassurance at the Ontario or Québec address matching their province of residence, or through the secure website listed with each address, within 90 days of the diagnosis.
Who pays
The important notice and each medical form state that the claimant pays any fees requested to complete them.

Good to know

  • Attach a photocopy of the clinical notes or test results, such as an imaging report; the notice says no comments may be added to the physician's section and the notes must not be modified.
  • For stroke, the statement asks whether neurological after-effects were present 30 days after the event; it also asks about HIV-related illness and use of drugs not prescribed by a doctor.
  • The medical statement is needed only if the insured person received out-patient treatments such as chemotherapy or radiation therapy, home nursing care or ambulance transport, and original bills must be attached.
  • The notice prefers blue ink for signing the authorizations because some hospitals may mistake a form signed in black ink for a photocopy.

Get the official form

Download the current version from the source each time; forms change without notice.

Critical Illness Claim Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it 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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How this list is checked

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What is the deadline for a Blue Cross critical illness claim?

The claim forms must be submitted to the insurer within 90 days of the diagnosis. The deadline is printed on the Claimant's Statement, the important notice and the Attending Physician Statement, so the physician's part needs to be completed and returned to the patient in time for the claimant to meet it.

Who pays for the Blue Cross critical illness attending physician statement?

The claimant. A note at the bottom of the Attending Physician Statement (01QRM0084A) says the claimant must pay any fees requested to complete the form, and the important notice repeats this for both the attending physician statement and the medical statement.

Can the claimant add notes to the physician's section?

No. The important notice states that no comments may appear in the section completed by the physician and that the physician's notes must not be modified. Any extra details or comments about the information given must be provided on a separate sheet attached to the claim.