Physician's proof-of-death statement for iA Special Markets (association/affinity group) accidental death claims.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Language
- English
iA F13-1109A: Exception Drug Authorization Request
iA Financial Group uses this one-page request to assess an exception drug under its personalized coverage program, which iA lists among individual insurance claims rather than group forms. A prescriber meets it when a patient with this coverage is prescribed a drug that needs authorization. The prescriber justifies the request and gives the diagnosis, and iA uses the form to review the drug claim.
Who completes it
The plan member or patient completes and signs Section 1; Section 2 is completed by the prescriber, who may be a doctor, resident doctor or dental surgeon, and includes the prescriber's 'Régie' application number and signature.
Submitting and payment
- How to submit it
- The form prints no return address; iA's claims page says the member's advisor guides them through the claims process, with advisor contact details in the contract documents or My Client Space.
Good to know
- Use a separate form for each medication; each one records the drug's name, form, potency, dosage, treatment start and end dates, and whether it will be given in hospital.
- Section 1 asks whether the patient receives or has applied for financial assistance from another source, such as a provincial or patient assistance program, with a copy of the response.
- The justification box should hold any relevant information useful to the assessment, and the diagnosis is entered separately below it.
- The current English version is dated July 2025 and is fillable; iA also lists a French version, 'Demande d'autorisation d'un médicament d'exception'.
Get the official form
Download the current version from the source each time; forms change without notice.
Authorization Request – Exception drug – personalized coverage program
Demande d’autorisation d’un médicament d’exception
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
Who can sign iA's exception drug authorization request?
Section 2 is for the prescribing physician, which the form defines as a doctor, resident doctor or dental surgeon. The prescriber enters name, address, 'Régie' application number, phone, fax and email, then signs and dates the request after describing the medication, justification and diagnosis.
Can one iA F13-1109A form cover several drugs?
No. The form tells prescribers to use a separate form for each medication requested. Each form identifies one drug by name, form and potency, with its dosage, treatment dates and whether it will be administered in hospital, plus its own justification and diagnosis.
Is F13-1109A for group or individual insurance?
iA lists the exception drug authorization under individual claims, tied to its personalized coverage program, and it does not appear among iA's group insurance drug forms. Group plan members use different iA forms, such as the F54-859A request for prior authorization of drugs.