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SAAQ Rapport d'évaluation (4066): Assessment Report

The SAAQ uses this report to get a clear picture of a road-accident victim's overall health. When it needs one, it sends the physician or specialized nurse practitioner (IPS) a pre-identified report with a matching receipt or invoice. The two-page report covers medical history, symptoms and clinical signs, tests and consultations, diagnosis, treatment and functional limitations, followed by a billing page.

Who completes it

The patient's physician or IPS completes Section 2 (the clinical report) and Section 3 (comments), signs without using a stamp, and then fills either the receipt or the invoice on the last page. Section 1 holds the accident victim's identification, claim number and communication number.

Submitting and payment

How to submit it
Send a copy to the SAAQ through its online document service for external providers, by fax or by mail, and give the original to the accident victim. Filling the PDF on screen carries the victim's details onto the receipt or invoice page.
Who pays
The SAAQ pays only when it requested the report, either directly to you through the invoice (Section 4) or by reimbursing a victim who paid you, using the receipt (Section 3), up to its authorized maximum.

Good to know

  • Section 2.1 covers prior trauma, surgical, medical and psychiatric conditions, medication at the time of the accident, and whether earlier limitations already made the patient permanently unfit for work.
  • Any medication that is not on the basic prescription drug insurance plan's list needs a written justification in Section 2.5.
  • Section 2.6 describes limitations under mobility, tolerance to effort, postural tolerance, activities of daily living and psychological or cognitive functions.
  • Enclose copies of the imaging and consultation reports you cite in Section 2.3; the English version, 4066A 30, is reserved for professionals without a Quebec address.

Get the official form

Download the current version from the source each time; forms change without notice.

Assessment Report and Receipt or Invoice for a Report

Rapport d'évaluation et reçu ou facture

Official pagePDFVersion française

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.

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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

Does the SAAQ pay for an assessment report it did not request?

No. The SAAQ reimburses the Rapport d'évaluation (4066) only when it asked for it beforehand, and it sends a pre-identified report with the matching receipt when it does. The initial report after an accident (4065) is the exception: the SAAQ reimburses it even when it did not request it.

Who can use the English Assessment Report (4066A)?

Only health professionals who do not have an address in Quebec. The English form notes that the original document is in French: physicians and IPS based in Quebec use the Rapport d'évaluation (4066 30). Both versions have the same sections, the same receipt or invoice page for a medical report and the same three ways to send it.

What is the difference between the SAAQ assessment, progress and after-effects reports?

All three are requested by the SAAQ after a road accident and share one receipt or invoice page. The assessment report (4066) gives the victim's overall health status, the progress report (4067) is requested when recovery differs from what was expected, and the after-effects report (4068) assesses whether permanent sequelae remain from the accident injuries.