CONSENTEMENT À LA DIVULGATION D'INFORMATIONS

Beneficiary (Patient)*

First nameLast name

Date of birth*

File number*

Home address*

Street Address

Apartment/address complement

CityProvince

Postal code

Country*

Pays*

To assess my application for benefits, I authorize any physician, practitioner, hospital or medical facility, insurance company, or any other organization, institution or person, who have information required to analyze my application, to convey that information to CanAssistance inc. or its representative and to my insurer. I understand that said information may be disclosed when necessary to their reinsurers, to internal and external auditors and to any professional or organization mandated by CanAssistance inc. or the insurer within the context of processing my application for benefits.

A photocopy or an electronic version of this authorization shall be as valid as the original for the duration of the claim settling.

I understand that I have the right to receive a copy of this authorization.

If insured is a minor, the parent or tutor must sign. If insured is incapable or deceased, the next of kin or the personal representative must sign.

In case of incapacity, please specify:

I, First and last name*, certify that the information provided above on this form is true and correct. Yes*

Je, Prénom et nom* , certifie que les informations fournies ci-dessus sur ce formulaire sont vraies et exactes. Oui*

Relationship if signed by other than insured

Parent, legal guardian, etc.

{input461:3}

______________________________

Electronic signature

{input471:3}

______________________________

Signature électronique

Date

- * By checking this box and sending us this consent form, you understand that we will process your personal information in accordance with the terms of our Privacy Policy. We invite you to read our Privacy Policy available on our web site, which provides, without limitation, information about the categories of third parties to whom it is necessary to communicate your personal information, sometimes outside your province of residence, and your rights to access and correct your personal information.

Please confirm that you are a human being*

AUTHORIZATION FOR RELEASE OF INFORMATION