Physicians and specialized nurse practitioners (IPS) complete this SAAQ report at the first medical consultation after a road accident. It documents accident-related injuries, pre-existing conditions, treatment, functional limitations and expected disability so the victim can claim compensation from the SAAQ. The attached invoice lets the SAAQ pay the physician directly, and the report is reimbursed even if the SAAQ did not ask for it.
The physician or IPS completes Section 2 of the report, the parking-permit question and the clinician block, and the physician's supplier number and fees go in Section 1 of the invoice. The accident victim, or a representative, signs the invoice authorization that lets the SAAQ pay the physician directly.
The first page is an instruction sheet, not a form. It reminds you that when you send your invoice to the SAAQ for payment, you must not enclose the corresponding initial report. Instead, give the report to the accident victim, who forwards it to the SAAQ, if applicable, with the claim for compensation (Demande d'indemnité).
Print the accident victim's name and the SAAQ claim number if known (numéro de réclamation si connu). The French version asks for the name at birth and first name. The note to the victim on the same page tells them to send the report after their claim for compensation has been filed online or by phone.
Give the date of the accident, the date of the examination and, if applicable, the date of death. Describe the injuries or diagnoses related to the accident, specifying the location of any skin injuries. In the next box, note current or pre-existing medical conditions that could affect how the injuries progress, keeping them separate from accident-related diagnoses.
Indicate whether treatment was prescribed and tick each type: medication, surgery, physiotherapy, occupational therapy, chiropractic, acupuncture, psychotherapy or other. A medication not on the RGAM list (the basic prescription drug insurance plan) requires a written justification under the exceptional patient measure. Then say whether there are functional limitations or restrictions, describe them, and choose the expected duration (1 week or less, 1 to 4 weeks, more than 4 weeks) with an end date if known.
State whether the accident-related injuries are likely to result in permanent impairment (séquelles permanentes) or scars, answering yes, no or cannot say. Indicate whether you will provide the patient's clinical follow-up and the date of the next appointment, and whether you want an SAAQ representative to contact you: yes, as needed or no.
Answer whether the person has a disability causing a loss of independence, or a risk to health and safety when travelling, for at least 6 months, and if so whether a permanent or temporary permit is required. The person must also meet the eligibility conditions published on the SAAQ website.
Print your name, professional licence number, address, telephone, fax and email, and tick general practitioner, IPS or specialist, naming the specialty. Sign by hand and date the report: the form specifies that a stamp must not be used for the signature. Keep a copy for your own files, as the form instructs.
Section 1 takes the physician's supplier number, licence number, name, address, telephone and amount claimed, and names another payee if fees are not paid to the physician. Section 2, the victim's authorization, is mandatory for payment; a spouse, close relative or person showing special interest may sign if the victim cannot and has no authorized representative. Section 3 adds an optional reference number for your reconciliation and the accident date.
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Initial Report and Invoice for an Initial Report
Rapport initial et facture
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Sources for this guide
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Yes, as the Initial Report and Invoice for an Initial Report (4065A 30), but the SAAQ reserves its English forms for health professionals who do not have an address in Québec. Clinicians practising in Québec use the French Rapport initial et facture (4065 30). The English version notes that the original document is in French.
The accident victim does. The physician gives the original report to the victim or their representative, who sends it to the SAAQ after filing a claim for compensation online or by phone. The physician sends only the invoice for payment, and the form asks that the report not be enclosed with it.
Yes. The SAAQ states that the initial report is reimbursed even if it did not request it beforehand. Fees are paid directly to the physician, or reimbursed to a victim who paid them, up to the SAAQ's maximum. Direct payment requires the victim's signed authorization in Section 2 of the invoice.
Yes. Section 2 of the report is headed for completion by the physician or the specialized nurse practitioner (IPS), and the clinician block lets you identify yourself as a general practitioner, IPS or specialist. The SAAQ invites the physician or IPS to complete it at the first medical consultation after the accident.