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Claimants: Essential Information : Is Your Initial Claim Complete?

Is Your Initial Claim Complete?

A Submission Checklist

Below, we have identified the forms you need to fill out when presenting a Claim and the steps you need to take for each one.  Please review them thoroughly before you submit your claim.

Form TRAN 1 / HEMO 1

This form identifies the Claimant (including his or her Type) and the HCV Infected Person.  Make sure you:

  • Complete all sections.
  • Sign the Form, where indicated.
  • Attach a positive antibody/PCR test result.

Form TRAN 2 / HEMO 2

This form confirms the Opinion of the Doctor and/or Specialist – It must be completed by a Physician.

  • Did the Physician sign the Form?
  • Did the Physician select a disease level?
  • Did the Physician complete Sections E, F, and G of the Form?
  • Attach all medical documentation supporting the selected disease level.

Form TRAN 3 / HEMO 3

Claimant Declaration Made Under Oath

  • Complete sections A, B, and C.
  • Sign in front of a Commissioner of Oaths – ensure that the individual is a Commissioner of Oaths.
    IMPORTANT! Be sure to ask this individual to confirm that he or she is a Commissioner of Oaths
    .

Form TRAN 4

Administrator to Directly Handle Your Traceback Search

  • Sign the Form in the presence of a witness.

Please Note:
All communication between the Administrator and Canadian Blood Services (CBS)/Héma-Québec is strictly confidential. If this form is unsigned, the Administrator cannot deal with CBS/Héma-Québec on your behalf.

Form TRAN 5

Transfusion History = All Blood Unit Numbers & Type of Blood Product Received

  • Complete all sections.
  • Attach all blood transfusion records, even pre-1986 transfusions.
  • Attach all correspondence from Canadian Blood Services or Héma-Québec.

Form GEN 5

Your Authorization (Optional but Recommended)

  • List all people or facilities that we may contact.
  • If this form is unsigned, the Administrator cannot speak directly with Doctors, clinics or hospitals, if ever necessary.

Form GEN 6

Your Authorization (Optional but Recommended)

  • If this form is unsigned, the Administrator cannot speak directly with Doctors, clinics or hospitals or other facilities in Québec, if ever necessary.

Form GEN 7

Provincial Hepatitis C Compensation Release of Information to Claims Centre

  • Complete this form if you have applied for and/or received provincial compensation.

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