The SAAQ sends this three-page questionnaire to the attending physician when recent medical reports say a road-accident victim cannot return to work. The answers help the SAAQ assess the overall situation, compensate the person properly and decide whether to refer them to rehabilitation. Disability is judged against a described job or, if the person had no job at the time of the accident, a presumed job based on their training and experience.
The attending physician answers the four questions, can use the page 3 restrictions chart, and signs both the questionnaire and the fee invoice; the SAAQ lists it among its forms for physicians and specialized nurse practitioners (IPS). The SAAQ's compensation officer completes and signs the cover letter, which carries the claim and health insurance numbers.
Download the current version from the source each time; forms change without notice.
Complementary Medical Information – Disability
Information médicale complémentaire – Incapacité
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When your recent medical reports say a road-accident victim cannot return to work and the SAAQ needs more detail on their functional limitations and ability to hold a job. The questionnaire comes with a cover letter from the compensation officer and a description of the job to consider, which may be a presumed job if the person was not employed.
Yes, as Complementary Medical Information, Disability (7484A 30), but the SAAQ reserves it for health professionals who do not have an address in Quebec, and it notes that the original document is in French. Physicians based in Quebec use the French version, 7484 30. Both versions have the same four questions and the same functional restrictions chart.
Yes. The first page is an invoice for the questionnaire: enter your name, licence number and professional fees, sign it, and the SAAQ pays the fee when it receives the completed questionnaire. Send the invoice and questionnaire together through the SAAQ's online document service, by fax or by mail.