Maladies graves – Déclaration du médecin
Family of condition-specific physician statements for Humania critical illness claims.
- Completed by
- Attending physician
- Issued by
- Humania
- Format
- Language
- French
Humania 4300-021: Rapport supplémentaire physique
This French-only supplementary report updates Humania on an ongoing disability claim caused by a physical illness. The attending physician documents objective examination findings, treatment, functional limitations at the start of the disability and now, and the expected duration of incapacity and return to work. Humania lists it with its administration forms as 4300-021, alongside a psychological illness version with the same number.
Who completes it
The attending physician completes Part 2 (Déclaration du médecin traitant) and the treatment and follow-up sections, then identifies themselves in Part 3 with their licence number and signature. The insured person completes Part 1 with their name, contract and certificate numbers, social insurance number and date of birth.
Submitting and payment
- How to submit it
- Part 2 is to be filled in block capitals and handed back to the patient. Humania accepts forms by online request where available, email, fax or mail, and recommends secure channels because email is less secure.
- Who pays
- A note on the form states that the fees for completing it are assumed by the insured person.
Good to know
- Attach copies of recent results, X-rays, ECGs or other tests supporting the objective findings, and a copy of any specialist consultation report.
- Symptom severity is graded léger, moyen or intense, and the form asks for weight, height and the most recent blood pressure.
- If you expect the absence to last beyond the usual period for the diagnosis, the form asks you to state the factors justifying your prognosis.
- Return to work is recorded as an approximate number of days or weeks, or a date, and as part time, full time or progressive.
Get the official form
Download the current version from the source each time; forms change without notice.
Maladie à caractère physique – Rapport supplémentaire
Fill it with Vero
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.
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.
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Frequently asked questions
Is Humania form 4300-021 available in English?
Humania publishes 4300-021 in French only, as Maladie à caractère physique, Rapport supplémentaire, with a separate version for psychological illness under the same number. The physical illness version on Humania's forms page carries the code 4300-021-fr-phy and is dated 2017/11.
Who pays for Humania's physical illness supplementary report?
The insured person. A note at the end of the form states, in French, that the fees for completing it are assumed by the insured person. The physician's section is completed in block capitals and handed back to the patient, with copies of supporting results and any specialist report attached.
How does the physical illness report differ from the psychological version?
Both carry number 4300-021. The physical illness version asks for objective examination and investigation findings, weight, height and blood pressure, and functional limitations at onset and now. The psychological version instead asks for signs and symptoms, DSM-IV axes, psychosocial stressors and a global assessment of functioning score.