Consolidated Statutes and Regulations
Consolidated Statutes
Consolidated Regulations
Annual Statutes and Regulations
Annual Statutes
Annual Regulations
Additional information
Québec Official Publisher
What’s new?
Information note
Policy of the Minister of Justice
Laws: Amendments
Laws: Provisions not in force
Laws: Provisions brought into force
Annual Statutes: PDF versions since 1996
Regulations: Amendments
Annual Regulations: PDF versions since 1996
Court Decisions
A-29, r. 5 - Regulation respecting the application of the Health Insurance Act
Schedule
Disposition versions
FORM 1
(Revoked)
FORM 1
(s. 28)
NOTICE OF WITHDRAWAL, OF REENGAGEMENT OR OF NON-PARTICIPATION
Date ______________________________
The President and Chief Executive Officer
Régie de l’assurance maladie du Québec
P.O. Box 500
Québec, (Québec)
G1K 7B4
Sir,
I, the undersigned __________(Name and surname in capital letters)__________ health professional practising my profession as: (check mark (√) the appropriate mention)
— a professional subject to the application of an agreement ( )
— a professional withdrawn ( )
— a non-participating professional ( )
notify the Régie de l’assurance maladie du Québec that I intend to practise my profession as: (check mark (√) the appropriate mention)
— a professional subject to the application of an agreement ( )
— a professional withdrawn ( )
— a non-participating professional ( )
in accordance with the Health Insurance Act (chapter A-29).
__________(Signature)__________
Profession ______________________________
Professional’s number ______________________________
Professional’s address ______________________________
__________(No.)__________(street)__________(City)__________(Postal Code)__________
