Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by filling out section A, which is for the patient’s identification. Enter the patient’s last name, first name, and relationship with the member, such as spouse or dependent child. Be sure to include the member’s last name, first name, contract number, and their address, including city, province, and postal code.
3. Provide the date of birth for the patient in the required format (YYYY-MM-DD) and fill out the telephone numbers for home and office if applicable. Indicate how you want to receive the response by selecting between fax or mail.
4. In section B, complete the declaration and authorization by confirming the accuracy of the provided information. You must sign and date this section, and include the name and signature of a parent or legal guardian if necessary.
5. Proceed to section C, which must be completed by the attending physician. The physician will provide their details, including name, license number, and address. They will also need to address the relevant medical information concerning the treatment.
6. Ensure that your physician completes all necessary details regarding the diagnosis and treatments received or previously used, and obtain their signature.
7. Once all sections are completed, review the form for any missing information. It is essential that the information is complete to avoid rejection.
8. Finally, you can save the changes made to the form. Options may be available to download, print, or share the completed document for submission.

Complete your Canada Desjardins Insurance 10122E form online today to ensure a smooth claims process.