Service Canada uses this report when a person claims they were unable to apply for Canada Pension Plan benefits on time. The physician declares that the patient could not form or express an intention to apply and gives the start and end dates of that incapacity. If accepted, the application can be treated as made earlier than the normal retroactivity limit would allow.
The physician completes the whole report: the dates of incapacity, the medical condition and an opinion on the patient's capacity. Social Security Tribunal decisions show that nurse practitioners have also completed it.
Download the current version from the source each time; forms change without notice.
Declaration of Incapacity - Physician's Report
Déclaration d'incapacité - rapport du médecin
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You cannot. The Service Canada forms catalogue lists the title in English and French but offers no public download, so Service Canada supplies the form on request. Contact the Service Canada office handling the application if you need a copy to complete.
The report is titled a physician's report, and Service Canada's fee table refers to it as the Declaration of Incapacity, Physician's Report. Social Security Tribunal decisions show nurse practitioners have also completed it. If you are unsure whether your signature will be accepted, ask the Service Canada office that sent it.
Yes. The French title is Déclaration d'incapacité - rapport du médecin, and Service Canada lists the form in both official languages. Because it is supplied directly rather than downloaded, ask the Service Canada office handling the file for the French version if your patient needs it.