Canada Life uses this five-page form to assess a Quebec group plan member's drug claim under the Quebec Exception Patient Program. Canada Life's page also asks members to contact their doctor to apply to the program. The physician section asks detailed questions on diagnosis, therapeutic goal, functional limitation and prior treatments, with RAMQ's List of Medications as the reference.
The plan member completes the Patient Information pages and signs the privacy consent; the prescribing physician completes the Physician Information pages, 18 numbered questions, and signs with a licence number.
Download the current version from the source each time; forms change without notice.
Quebec Exception Patient Program Form
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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It collects the information Canada Life needs to assess a Quebec plan member's drug claim under the Quebec Exceptional Medications and Exception Patient Program. Canada Life also asks members to contact their doctor to apply to that program, and the physician refers to RAMQ's List of Medications when completing it.
The plan member or patient. Page one states that any costs incurred for completing the form are their responsibility. Canada Life also asks that every question be answered, since an incomplete form or one containing errors delays the claim assessment.
Yes. Canada Life says to use Adobe Reader XI or higher rather than a web browser, then save the file; members can also print it and complete it by hand. All pages then go to Drug Claims Management by mail, fax or email.