26. Any professional who practises his profession outside the scope of the plan as a non-participating professional shall, except in cases of emergency determined by the Act and the regulations, inform an insured person in writing that the insured person must assume the full cost of the professional services he is intending to request.
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 NON-PARTICIPATION
To insured persons under health insurance plan
I notify you that I am a professional non-participating in the Health Insurance Plan. As such, I may not claim payment of my fees from the Régie de l’assurance maladie du Québec.
If you have recourse to my professional services, you must therefore pay me directly the cost of insured services I will dispense to you.
You may neither demand or obtain from the Régie de l’assurance maladie du Québec the reimbursement of the cost of insured services which you will have paid to me.
This notice is given to you in accordance with the Health Insurance Act (chapter A-29) and the regulations.
__________(name of non-participating professional)__________