C-26, r. 161 - Regulation respecting the procedure for conciliation and arbitration of accounts of nursing assistants

Schedule Disposition versions

2012-09-01

SCHEDULE 1

(s. 2.02)

APPLICATION FOR CONCILIATION

I, the undersigned __________(name and address)__________ in person or (where applicable) representing ______________________________ for the purposes of this application, as attested by the authorization annexed hereto, being duly sworn, declare that:

(1) __________(name of professional)__________ claims from me the sum of __________ for professional services rendered between ______________________________ and ______________________________, as attested by the account a copy of which is annexed hereto;

Check the appropriate box

(2) I refuse to pay this account □

or

I ask for a reimbursement of $__________ □

for the following reasons:

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(3) I apply for conciliation by the syndic pursuant to Division II of the Regulation respecting the procedure for conciliation and arbitration of accounts of nursing assistants (chapter C-26, r. 161), of which I declare having received a copy and taken cognizance.

And I have signed

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(signature of patient or his duly authorized representative)

Sworn before me

at __________________________________________________________________________________

this ____________________________________________________________________ 20__________

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Commissioner for oaths

R.R.Q., 1981, c. C-26, r. 117, Sch. 1; O.C. 1079-96, s. 5.