Quebec physiotherapy clinics use this one-page French claim, backed by a page of instructions, to bill the SAAQ for treatments given to a road accident victim. It lists the treatment period, number of treatments, unit rate and total, a day-by-day attendance calendar, and declarations by the treating professional and the victim. The SAAQ decides whether the costs relate to the accident and are necessary.
The clinic completes the victim, supplier and billing sections, and the physiotherapist or physiotherapy technologist who gave the treatments certifies them with a licence number. The victim or their representative signs to confirm receiving the treatments and asks the SAAQ to pay the provider directly.
Download the current version from the source each time; forms change without notice.
Demande de remboursement de frais de physiothérapie
Request for Reimbursement of Physiotherapy Costs
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Yes. Section 2 asks for the supplier number, which the SAAQ assigns to each clinic. Quote it with the claim number when sending questions through the SAAQ's secure email form, choosing Indemnisation as the subject and sending one email per claim.
The guide printed on the form says the SAAQ recommends that the clinic send its reimbursement request every month. Each form is produced in a single copy, and if the same request is sent again, tick the 2e envoi ou plus box on the first page.
No. The SAAQ publishes form 5695-30 in French only. It can be filled in on screen, then printed and signed, or printed and completed by hand before faxing. Clinics can order paper copies with order form 4189-35.