{"content":[{"text":"145 The West Mall, P.O. Box 110 U \n Toronto, ON. M8Z 5M4","bbox":{"left":0.723105,"top":0.056023,"width":0.23939699999999997,"height":0.028677999999999995}},{"text":"HealthWATCH® Drug Plan Specialty Solutions Program \n DEMANDE D'EXEMPTION","bbox":{"left":0.196699,"top":0.128633,"width":0.6038890000000001,"height":0.044713}},{"text":"Directives: \n 1. Section 1 doit être complétée par le membre du régime/patient \n 2. Section 2 doit être complétée par le médecin (les dépenses encourues pour cette fin sont la responsabilité du \n membre du régime)","bbox":{"left":0.037255,"top":0.190357,"width":0.855839,"height":0.060701000000000005}},{"text":"Prière de soumettre le formulaire complété à NexgenRx Provider Services par fax: 1-877-639-4369, par courrier postal: 145 \n The West Mall, CP 110U, Toronto, Ontario, M8Z-5M4, ou par courriel: providerservices@nexgenrx.com","bbox":{"left":0.037255,"top":0.26287,"width":0.89277,"height":0.03182400000000002}},{"text":"Ce formulaire NexgenRx deviendra la propriété de NexgenRx après signature autorisée et sera acheminé par courriel \n à HealthWATCH® Drug Plan Specialty Solutions Program une fois la révision par notre département/personnel complétée.","bbox":{"left":0.037255,"top":0.306607,"width":0.907779,"height":0.03171099999999999}},{"text":"Tous les champs doivent être complétés: Un formulaire incomplet pourrait résulter à un refus de \n votre application","bbox":{"left":0.044706,"top":0.34976,"width":0.9000779999999999,"height":0.03828799999999999}},{"text":"Section 1: Doit être completée par le patient","bbox":{"left":0.044706,"top":0.402033,"width":0.40851,"height":0.020863999999999994}},{"text":"Carrier ID","bbox":{"left":0.044706,"top":0.469334,"width":0.074294,"height":0.01731699999999997}},{"text":"Numéro, régime de groupe","bbox":{"left":0.159843,"top":0.469334,"width":0.20772800000000002,"height":0.01731699999999997}},{"text":"Numéro du certificat","bbox":{"left":0.42067,"top":0.469334,"width":0.158628,"height":0.01731699999999997}},{"text":"Code du \n patient","bbox":{"left":0.849608,"top":0.469334,"width":0.06517899999999999,"height":0.03186300000000003}},{"text":"9 8 \n Nom du membre: (Surnom, prénom)","bbox":{"left":0.044706,"top":0.513573,"width":0.263159,"height":0.04512400000000005}},{"text":"Employeur:","bbox":{"left":0.393415,"top":0.541418,"width":0.082596,"height":0.017279000000000044}},{"text":"Nom du patient: (Surnom, Prénom)","bbox":{"left":0.044706,"top":0.587541,"width":0.27101899999999995,"height":0.017317000000000027}},{"text":"Date de naissance du patient (JJ/MM/AAAA)","bbox":{"left":0.393415,"top":0.587479,"width":0.32278900000000005,"height":0.017279000000000044}},{"text":"Lien de parenté au \n membre \n Employé (e) \n Conjoint (e) \n Personne à charge","bbox":{"left":0.773693,"top":0.587479,"width":0.16112899999999997,"height":0.08409700000000009}},{"text":"Coordination des bénéfices: le patient a-t-il une couverture d'un autre fournisseur? \n Adresse complète du patient:","bbox":{"left":0.044706,"top":0.681266,"width":0.594288,"height":0.04222899999999996}},{"text":"Oui _____ Non _____","bbox":{"left":0.675205,"top":0.681266,"width":0.16023299999999996,"height":0.017279000000000044}},{"text":"Numéro \n d'appartement","bbox":{"left":0.232778,"top":0.761304,"width":0.103685,"height":0.0318250000000001}},{"text":"Adresse civique","bbox":{"left":0.044706,"top":0.768577,"width":0.11504400000000001,"height":0.017279000000000044}},{"text":"Ville","bbox":{"left":0.361454,"top":0.768577,"width":0.030612000000000028,"height":0.017279000000000044}},{"text":"Province","bbox":{"left":0.667614,"top":0.768577,"width":0.06330800000000003,"height":0.017279000000000044}},{"text":"Code postal","bbox":{"left":0.848823,"top":0.768577,"width":0.087086,"height":0.017279000000000044}},{"text":"1 of 4","bbox":{"left":0.480507,"top":0.94536,"width":0.03699899999999989,"height":0.015614000000000017}}],"images_bbox":[{"left":0.04469,"top":0.057576,"width":0.231944,"height":0.050126}],"images_bbox_not_text_overlap":[{"left":0.04469,"top":0.057576,"width":0.231944,"height":0.050126}]}