External Breastforms – Procedure to Follow

To receive the first $200 payment, you must:

• complete the registration form;
• provide proof of purchase of the breastform and an original medical certificate or an original medical report, as the case may be;
• send the form and the documents to the following address:

  Régie de l'assurance maladie du Québec
  External Breastforms Program (Q039)
  PO Box 6600
  Québec (Québec) G1K 7T3

Every two years thereafter, the Régie will automatically send you a payment covering the cost of replacing the breastform. Remember to notify the Régie of any change of address, since the Régie will send the payment to the address it has on file.

The proof of purchase must be the original and must contain the following information:

• the name, address and telephone number of the commercial establishment at which the breastform was purchased;
• the date of purchase;
• a description of the breastform;
• the price of the breastform;
• the insured person's full name.

The original medical certificate must contain the following information:

• the date of the operation;
• the type of operation (total or radical mastectomy);
• the insured person's full name.

The original medical report must attest to a total absence of breast formation.

The medical certificate or medical report must be dated and signed, and must clearly show the physician's name and professional number.

For general information about the program, consult the pamphlet.