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 psychologique
This French-only supplementary report updates Humania on an ongoing disability claim caused by a psychological illness. The attending physician grades signs and symptoms, lists treatment and the professionals involved, completes DSM-IV axes II to V with a global assessment of functioning score, and estimates the duration of incapacity and the return to work.
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 identification, contract and certificate numbers.
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 warns that email is less secure for confidential information.
- Who pays
- A note on the form states that the fees for completing it are assumed by the insured person.
Good to know
- Treatment questions ask whether the patient sees a psychiatrist, psychologist, social worker or other professional, and whether care is in a treatment centre, CLSC, day hospital, group or individual therapy.
- Axis IV lists psychosocial stressors from the last 12 months, including job loss or layoff, work, marital or family problems and substance or gambling issues.
- Axis V asks for the DSM-IV global assessment of functioning (EGF) score, from 0 to 100, at the start of treatment and currently.
- The form asks whether the patient's condition has improved optimally and whether they would benefit from assistance with a return to work.
Get the official form
Download the current version from the source each time; forms change without notice.
Maladie à caractère psychologique – Rapport supplémentaire
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.
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 there an English version of Humania form 4300-021 for psychological illness?
Humania publishes the form in French only, as Maladie à caractère psychologique, Rapport supplémentaire. The version on Humania's forms page carries the code 4300-021-fr-psy and is dated 2017/05, and a physical illness version carries the same 4300-021 number.
Who pays for Humania's psychological 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.
Does Humania still use DSM-IV axes on this form?
Yes. The 2017/05 version asks for Axis II personality disorders and associated substance, alcohol or gambling problems, Axis III associated illnesses and medications, Axis IV psychosocial stressors in the past 12 months, and an Axis V global assessment of functioning score on the DSM-IV 0 to 100 scale.