25. Any professional who has withdrawn shall, except in the cases of emergency determined by the Act and the regulations, inform an insured person in writing that if the insured person avails himself of the professional’s services, he must claim the cost of the services directly from the Board.
This notice must be signed by the professional, bear the date of issuance, be drawn up in the manner prescribed hereafter and be delivered by hand in advance by the professional to any insured person who avails himself of the professional’s services:
NOTICE OF WITHDRAWAL
To insured persons under health insurance plan
This is to notify you that I am a professional who has withdrawn from the health insurance plan.
If you avail yourself of my professional services, you must send the statement of fees that I must complete and return to you to the Board. When the Board has paid you after you have submitted the statement of fees and the information prescribed in the Act, you must pay the cost of insured services I have furnished directly to me.
The cost that I will claim for these insured services will be in accordance with the tariff payable by the Régie de l’assurance maladie du Québec.
You have been given this Notice in accordance with the Health Insurance Act (chapter A-29) and its regulations.
__________(signature of professional who has withdrawn)__________