1 Identity of the person whom you are representing 2 Contact information of the person whom you are representing 3 Your identity and your contact information 4 Your message 5 Summary 6 Fin webform_started File a complaint on the quality of services on behalf of someone else Unless otherwise instructed, you have to fill out all the fields. Identity of the person whom you are representing Identity of the person whom you are representing First and last names Numéro d’assurance et Date naissance Health Insurance Number Date of birth Social Insurance Number Health Insurance Number Example: AAAA 9999 9999Four letters “A”, followed by four nines, followed by four nines Date of birth Example: 31/01/1955Thirty-one, then slash, then zero one, then slash, then nineteen fifty-five Social Insurance Number Example: 999 999 999 Relation with you Example: Parent, friend Form submission language :Complaint or comment :Souhaitez-vous proposer des pistes de solution au problèmeIdentification of the representative :Identification of the complainant :Do not have a health insurance number :Do not have a health insurance number.Reside outside Québec :Reside outside Québec ext.Relation :app. Leave this field blank
