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

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

First and last names

Health Insurance Number

Date of birth

Social Insurance Number

Health Insurance Number

Example: Four letters “A”, followed by four nines, followed by four nines

Date of birth

Example: Thirty-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.