A-29, r. 5 - Regulation respecting the application of the Health Insurance Act

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26.1. Any physician in a period of training to obtain his first specialist’s certificate shall, except where the services are furnished in a centre operated by an institution other than the institution with which he is in a period of training or for the Corporation d’urgences-santé, inform an insured person in writing that the services the insured person intends to request are not insured and that the insured person must assume the full cost of the services.
The notice must be signed by the physician, bear the date of issue, be drawn up in the manner prescribed below and be delivered by hand in advance by the physician to any insured person who avails himself of the professional’s services:
To insured persons under health insurance plan
I inform you that I am a physician in a period of training to obtain my first specialist’s certificate. As such, I may not claim, payment of my fees from the Régie de l’assurance maladie du Québec for services which I render on a private basis, which services are not insured.
If you have recourse to my professional services, you must therefore pay me directly the cost of services which I will dispense to you on a private basis.
You may neither request or obtain from the Régie de l’assurance maladie du Québec the reimbursement of the cost of the 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 regulations thereunder.
__________(signature of physician in a period of training)__________
O.C. 13-83, s. 2; O.C. 1469-92, s. 5; O.C. 1179-95, s. 5.