To use the Add to cart function, you must change your Web browser’s parameters to accept cookies. Once the parameters have been changed, you must refresh the Web page.
This form is to be used by the physician to submit to Retraite Québec report on the state of health of a person who has applied for disability benefits.
electronic signature is accepted on this form.
Notice to disabled persons
Insurance companies can use this form to obtain an applicant's consent to the reimbursement of disability benefits to the insurer. This form is also used to file the insurer's application for remittance.
By signing this form, you are agreeing to file an application subsequently for disability benefits with Retraite Québec. We recommend that you review the clauses of your contract with your insurance company because you may not be required to complete the form.