Desjardins Insurance requests this form for clinical information supporting a group plan claim for home nursing care. The attending health care professional summarizes the disability, prognosis and any surgery, specifies the level of care and hours per day, and states whether someone with lesser qualifications could provide the care. Incomplete forms cannot be processed and are returned to the plan member.
The attending health care professional completes Section B (patient information) and Section C, giving their title, professional association and licence number. The plan member, or their legal representative, completes Section A.
Download the current version from the source each time; forms change without notice.
Home nursing care - Request for additional information
Soins infirmiers à domicile - Demande de renseignements supplémentaires
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The plan member. A notice at the top of the form states that the plan member must pay the fees requested to complete it. Desjardins also warns that incomplete forms cannot be processed and will be returned to the plan member, so every question should be answered.
Section B asks for the level of care required (R.N., R.N.A. or other), a detailed description of tasks completed or in progress, and whether someone with lesser qualifications could provide the care, with an explanation if yes. It also asks for hours per day and the duration of care.
The form is addressed to the attending health care professional rather than only to a physician. Section C asks for the professional's title, professional association and licence number, so the signer identifies their profession and regulatory body along with their signature and date.