I-8, r. 17 - Regulation respecting the procedure for conciliation and arbitration of accounts of nurses

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) Mr

Ms __________(name of nursing 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;

(2) I refuse to pay this account for the following reason(s):

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but (where applicable) acknowledge that I owe the sum of ______________________________ for the professional services referred to in such account;

(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 nurses (chapter I-8, r. 17), of which I declare having received a copy and taken cognizance.

Sworn before me at ___________________________ this ___________________________ 20 __________

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(Commissioner for oaths)

And I have signed

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(signature of client or his duly authorized representative)

R.R.Q., 1981, c. I-8, r. 10, Sch. 1.