A-29, r. 4 - Regulation respecting devices which compensate for a physical deficiency and are insured under the Health Insurance Act

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34.2. The Board assumes the cost of a service as well as the cost of the purchase, replacement, fitting or repair of a device or other equipment referred to in this Title only if the institution or laboratory sends to the Board, using the form provided by the Board, the following information, which may vary depending on the medium used or depending on whether the reference “S.C.” appears in place of the purchase or replacement price or the case involves a claim for payment:
(1)  the health insurance number, the expiration date indicated on the health insurance card and the information required by the Board to identify the insured person who benefited from the property or service;
(2)  the name, permit number and dispenser number of the institution or laboratory, and the prescriber number and the reference number of the claim concerning a device, component or supplement for which the reference “S.C.” appears in place of its purchase or replacement price or of the claim for payment;
(3)  a description of the insured person’s physical deficiency and disability, and the information provided for, as the case may be, in sections 4, 23 and 27;
(4)  the code of the good or service, side of the body, type, the number of units, the amount claimed, the serial number, the date on which the property was allocated or the service rendered and, in the case of a repair, fitting, replacement or adjustment, the reason therefor, the date of taking possession, the reference code for the property and the manufacturer’s authorization number;
(5)  a statement of the labour costs, including the duration of the work and a list of the materials;
(6)  a statement by the insured person confirming that the person received the property or service described and authorizing the Board to make the payment;
(7)  the necessary information for identifying the recipient of the payment; and
(8)  a statement by the person in charge of the institution or laboratory confirming that the information provided is accurate and complete.
O.C. 1092-2011, s. 5.