[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-307934-105":59,"doc-detail-307934-en":130},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":123,"head_meta":125,"extra_data":127,"updated_unix":129},105,"en","claim-form-financial-assistance-program-for-users-2024","Claim Form - Financial Assistance Program for Users - 2024","","Claim Form (Financial Assistance Program for Users) collects personal, travel, and eligibility details needed to request financial assistance. Applicants complete SECTION 1 and, when applicable, SECTION 2 for an accompanying person, and SECTION 3 for a Bas-Saint-Laurent physician who prescribed the trip (or attach a prescription copy). SECTION 4 records the institution providing services, treatment, appointments, and hospitalization dates. SECTION 5 is reserved for CISSS du Bas-Saint-Laurent accounting, including acceptance/refusal, amount, quantity, and budget code. Supporting documents must be attached and original receipts kept for annual tax filing.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/claim-form-financial-assistance-program-for-users-2024/307934/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/claim-form-financial-assistance-program-for-users-2024/307934.png","ImageObject",300,407,{"name":92,"@type":93},"Skyler","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":102,"interactionType":103,"userInteractionCount":34},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What documents must be attached with the claim form?","Question",{"text":112,"@type":113},"Supporting documents must be attached to the form. If it is the first claim, attach a photocopy of the medical prescription from the Bas-Saint-Laurent physician and a void cheque.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What information should be completed in SECTION 1?",{"text":117,"@type":113},"SECTION 1 collects user identity details, contact information, health insurance card number, travel dates, transportation mode, and questions about prior claims and sources of financial assistance. It also includes authorization to check with relevant organizations.",{"name":119,"@type":110,"acceptedAnswer":120},"What does SECTION 3 require from the Bas-Saint-Laurent physician?",{"text":121,"@type":113},"SECTION 3 records the reason for referral (specialty), the doctor’s name, licence number, whether the closest institution offering the service is used, and whether accompaniment is required. It includes the physician’s or authorized person’s signature and date.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},307934,1790291743,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":34,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":81,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":39},2336464648746,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Claim Form  \n(FINANCIAL ASSISTANCE PROGRAM FOR USERS)  \nPlease ensure that SECTION 1, 2 (if applicable) 3 and 4 of this form are completed, and that supporting documents are attached to this form. Keep your original receipts for your annual tax return. Those you submit with your claim won’t be sent back to you. Incomplete forms will be returned to you.  \nPlease submit this form within 90 days of your trip to the following address :  \nCISSS du Bas-Saint-Laurent  \nService de la comptabilité  \n800, avenue du Sanatorium  \nMont-Joli (Québec) G5H 3L6 [aidefinanciere200km.cisssbsl@ssss.gouv.qc.ca](aidefinanciere200km.cisssbsl@ssss.gouv.qc.ca)  \nSECTION 1 User (please complete all fields)  \nLast Name :   First Name :   Adress :  \n\n| Civic No. | Street |\n| --- | --- |\n\nCity Province Postal Code  \nTelephone Home : ( ) Work : ( ) Number :  \nDate of Birth :   ⁄ ⁄  Health Insurance Card No. :  \nYear Month Day (RAMQ Card)  \nEmail :  \nMode of transportation : Initial trip :  \nTravel dates : Departure date :  \nReturn trip :  \nReturn date :  \nHave you already submitted a claim under this program?  \nDo you receive financial assistance from :  \n• Commission des normes, de l’équité, de la santé et de la sécurité du travail (CNESST)?  \n• Ministère du Travail, de l’Emploi et de la Solidarité sociale (social assistance)?  \n• Travel Expense Program for people with disabilities (refer to your CLSC)?  \n• Société de l’assurance automobile du Québec (SAAQ)?  \n• Other :  \nDo you authorize us to check with the appropriate organizations to identify the paying agent?  \n☐ Yes  \n☐ Yes  \n☐ Yes  \n☐ Yes  \n☐ Yes  \n☐ Yes  \n☐ Yes  \n☐ No  \n☐ No  \n☐ No  \n☐ No  \n☐ No  \n☐ No  \n☐ No  \nIf this is your first claim, please attach to this form a photocopy of your medical prescription from the Bas-Saint-Laurent physician (or have them complete SECTION 3 of this form)  \nand a void cheque.  \nUser’s signature :  Date :    \nSECTION 2 Accompanying person (if applicable)  \nLast Name :   First Name :   Address :  \n\n| Civic No. | Street |\n| --- | --- |\n\nCity Province Postal Code  \nTelephone : Home : ( )   Work : ( )    \nSECTION 3  \nBas-Saint-Laurent physician who prescribed the trip  \n(or attach a copy of the doctor’s prescription)  \nReason for referral (specialty) : Doctor’s name (print) :  \nLicence No. :   \nIs this the closest institution offering the service? ☐ Yes ☐ No  \nIf not, specify why:    \nDo you have to be accompanied by a family member If so, physician’s initials : or an attendant?  \nSignature of Bas-Saint-Laurent  \nphysician or autorized person :   Date :  \nSECTION 4 Institution that will be providing the required services  \n(STAMPA) Institution Name :  \nAdress :  \nCivic No. Street  \nCity  \nProvince  \nPostal  \nCode  \nName of out-of-region physician : Licence No. :    \nSpecialty :    \nTreatment received :    \nAppointment date :   ⁄ ⁄  Is this a follow-up? ☐ Yes ☐ No  \nYear Month Day  \nDate of hospitalization: From :  ⁄ ⁄  To :   ⁄ ⁄   \nYear Month Day Year Month Day  \nAccompanying person requested by physician : ☐ Yes ☐ No  \nService covered by the RAMQ : ☐ Yes ☐ No  \nSignature of out-of-region physician Date :    \nor authorized person :    \nSECTION 5 CISSS du Bas-Saint-Laurent (section reserved for Accounting Department)  \nReception date:  ⁄ ⁄   \nYear Month Day  \nThis request is :  \n\n| ☐ Accepted\u003Cbr>Amount :  \u003Cbr>Quantity :  \u003Cbr>Budget code :   | ☐ Refused\u003Cbr>Reason for refusal (if applicable) :  \u003Cbr>\u003Cbr>|\n| --- | --- |\n\nSignature of the accountant :   Date :","cbCaicUuLDUtggN3","https://ap.wps.com/l/cbCaicUuLDUtggN3","pdf",742228,"English","# SECTION 1 User\n## Eligibility and travel details\n## Authorization for verification\n# SECTION 2 Accompanying person\n# SECTION 3 Bas-Saint-Laurent physician\n## Referral reason and prescription\n## Whether the closest institution\n# SECTION 4 Institution providing services (STAMPA)\n## Treatment, appointment, hospitalization\n## Follow-up and covered services\n# SECTION 5 CISSS du Bas-Saint-Laurent accounting","[{\"question\":\"What documents must be attached with the claim form?\",\"answer\":\"Supporting documents must be attached to the form. If it is the first claim, attach a photocopy of the medical prescription from the Bas-Saint-Laurent physician and a void cheque.\"},{\"question\":\"What information should be completed in SECTION 1?\",\"answer\":\"SECTION 1 collects user identity details, contact information, health insurance card number, travel dates, transportation mode, and questions about prior claims and sources of financial assistance. It also includes authorization to check with relevant organizations.\"},{\"question\":\"What does SECTION 3 require from the Bas-Saint-Laurent physician?\",\"answer\":\"SECTION 3 records the reason for referral (specialty), the doctor’s name, licence number, whether the closest institution offering the service is used, and whether accompaniment is required. It includes the physician’s or authorized person’s signature and date.\"}]","Claim Form - Financial Assistance Program for Users - 2024 | PDF",1789857326]