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 Nursing Care Questionnaire (F54-898A)
iA Financial Group uses this questionnaire to determine whether a group plan member's request for private nursing care is eligible for reimbursement under the nursing care benefit, and members can send it for prior approval. The attending physician describes the condition requiring nursing care, the hours, level and duration of care and the nurse's specific duties; iA sends a confirmation letter after its review.
Who completes it
The attending physician completes the page 2 section headed To be completed by the attending physician, including the clinical information and a signed confirmation with licence number. The plan member completes page 1: basic information, place of residence, where services will be provided, the nature of fees and the authorization.
Submitting and payment
- How to submit it
- The form is mailed to iA's Group Health and Dental Claims, with one return address for Quebec and another for all other provinces printed on the form.
Good to know
- If care is needed for more than two weeks, the patient must register for home care assistance programs, such as a CISSS, CIUSSS or CLSC in Quebec or HCCSS in Ontario.
- Record the amount of care as hours per day and days per week, the expected start and end dates, and the level of care: RN, LPN or other.
- List medications with route of administration and frequency, attaching extra sheets if necessary, and describe the specific duties to be performed by the nurse.
- The plan member indicates whether the nursing fees relate to a work accident or a car accident and whether the patient lives in a long-term care facility or nursing home.
Get the official form
Download the current version from the source each time; forms change without notice.
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 the iA nursing care questionnaire available in French?
Yes. The French version, Questionnaire pour les soins infirmiers, is form F54-898, and the English version is F54-898A, revision 23-05. Both are published by iA Financial Group for group insurance plan members.
What does the physician complete on iA form F54-898A?
Page 2: a brief summary of the condition or diagnosis requiring nursing care, prognosis, hours per day and days per week of care, expected duration, level of care (RN, LPN or other), location, medications with route and frequency, specific nursing duties and comments, then your confirmation with licence number and signature.
When must the patient register with a provincial home care program?
The instructions say financial assistance programs exist for home care services and that the patient must register for them, based on their territory, if care is needed for more than two weeks. In Quebec that means a CISSS, CIUSSS or CLSC, and in Ontario Home and Community Care Support Services.