By checking this box, I confirm that the information provided is complete and accurate. Any false or fraudulent information may result in my claim being denied. I authorize Humania Assurance, its agents, service providers and other partners (hereinafter “Business Partners”) to collect, by any electronic means, email, fax or mail and to use all information relevant to the assessment of this claim, whether pertaining to me or my dependents. This information may also be used for statistical reporting purposes.
I further authorize Humania Assurance to share the personal information collected about me or my dependents to its Business Partners, whether located in or outside Quebec, where the exchange of such information is necessary to carry out their mandate.
This authorization applies to my personal information held by any natural or legal person, including but not limited to any physician or other health professional, any public or private health institution, any rehabilitation company, any pharmacist, any provincial health insurance plan, including but not limited to the Régie de l’assurance maladie du Québec, any insurer, any employer or any other person or institution in possession of medical or financial information about me. This authorization also applies to any other personal information contained on social media or on any Internet platform accessible to the public.
I declare that I am aware of the rights granted by the Act respecting the protection of personal information in the private sector, including but not limited to the right to access my information, the right to have that information corrected, if need be, and the right to withdraw, at any time, this authorization to share and use my personal information.