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.
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Form TRAN
1 / HEMO
1
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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.
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Form TRAN
2 / HEMO
2
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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.
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Form TRAN
3 / HEMO 3
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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.
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Form TRAN
4
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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.
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Form TRAN 5
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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.
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Form GEN
5
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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.
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Form GEN
6
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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.
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Form GEN
7
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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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