Provincial disability assistance forms for clinicians

Application for the Persons with Disabilities (PWD) designation under the EAPWD Act; the patient brings it to their physician/NP for the Medical Report and to a prescribed professional for the Assessor Report.

Completed by

Section 2: medical practitioner or nurse practitioner. Section 3: medical practitioner, NP or other prescribed professional (registered nurse/psychiatric nurse, OT, PT, psychologist, chiropractor, or registered social worker).

Issued by

BC SDPR

Format

Fillable PDF

Language

English

Request for ministry-funded medical equipment and devices (least costly item that meets a medically essential need) for assistance clients.

Completed by

Section 2: medical practitioner or nurse practitioner. Section 3: occupational, physical or respiratory therapist.

Issued by

BC SDPR

Format

Sent for each case

Language

English

Request for the Monthly Nutritional Supplement for a person with the PWD designation who has a chronic, progressive deterioration of health needing extra nutrition or vitamins.

Completed by

Medical practitioner, nurse practitioner or registered dietitian

Issued by

BC SDPR

Format

Sent for each case

Language

English

Health assessment used to determine whether an income assistance client qualifies for the Persistent Multiple Barriers (PPMB) category (health condition expected to last 2+ years that seriously impedes employment).

Completed by

Health professional: medical practitioner, nurse practitioner, registered nurse/registered psychiatric nurse, chiropractor, occupational therapist, physical therapist, registered social worker, psychologist, school psychologist or registered clinical counsellor

Issued by

BC SDPR

Format

Fillable PDF

Language

English

Pre-authorization request for ministry-funded orthoses (custom or off-the-shelf orthoses and knee braces) for assistance clients.

Completed by

Prescribing practitioner (Section 2); orthotist, pedorthist, occupational therapist or physical therapist (Section 3 Assessment)

Issued by

BC SDPR

Format

PDF

Language

English

Physician report on whether a client's medical condition affects their ability to seek, accept or continue employment (for medical-condition exemptions or categorisation of Expected to Work clients).

Completed by

Medical practitioner (physician registered with CPSBC; GP or specialist)

Issued by

BC SDPR

Format

Sent for each case

Language

English

Physician report on a child's physical or mental condition and the care it requires, used when a parent on assistance seeks an employment-obligation or earnings exemption because the child's needs prevent work of more than 30 hours a week.

Completed by

Medical practitioner (physician registered with CPSBC)

Issued by

BC SDPR

Format

Sent for each case

Language

English

Confirms a therapeutic diet (restricted sodium, diabetic, kidney dialysis, high protein for listed conditions, gluten-free, dysphagia, cystic fibrosis, ketogenic, low phenylalanine) so an income or disability assistance client can receive a diet supplement.

Completed by

Physician, nurse practitioner or registered dietitian

Issued by

BC SDPR

Format

Fillable PDF

Language

English

Request for a ministry-funded breathing device (e.g., CPAP/BiPAP and related equipment) for assistance clients, including Life-Threatening Health Need requests.

Completed by

Section 2: medical practitioner or nurse practitioner (or attach a written prescription). Section 3: respiratory therapist.

Issued by

BC SDPR

Format

Fillable PDF

Language

English

Medical report for applications to Assured Income for the Severely Handicapped (AISH) and/or the Alberta Disability Assistance Program (ADAP), describing diagnosis, functioning, limitations and prognosis.

Completed by

Health professional registered to practise in Alberta (normally the applicant's physician); NPs, specialists and allied health may assist

Issued by

Alberta Assisted Living and Social Services (AISH/ADAP)

Format

Fillable PDF

Language

English

Request for medically essential equipment and devices for clients of Employment and Income Assistance, Children's disABILITY Services or Community Living disABILITY Services.

Completed by

Section 2: regulated health professional (prescriber); Section 3a: any regulated health professional; Section 3b (specialized equipment): OT, PT, respiratory therapist or SLP

Issued by

Manitoba Families – Disability and Health Supports Unit

Format

Fillable PDF

Language

English

Request for medical supplies for EIA, Children's disABILITY Services or Community Living disABILITY Services clients.

Completed by

Health professional: physician, registered dietitian, registered physician assistant, registered nurse practitioner, LPN, RN, registered midwife, OT, PT, respiratory therapist or speech language therapist

Issued by

Manitoba Families – Disability and Health Supports Unit

Format

PDF

Language

English

Request for a therapeutic diet allowance or nutritional supplements (approval not to exceed 12 months) for EIA and disABILITY services clients.

Completed by

Health professional: physician, registered dietitian, registered physician assistant, registered nurse practitioner, LPN, RN, registered midwife, OT, PT, respiratory therapist or speech language therapist

Issued by

Manitoba Families – Disability and Health Supports Unit

Format

Fillable PDF

Language

English

Request for wheelchair seating components through the Materials Distribution Agency for DHSU program clients.

Completed by

Health professional (typically OT or PT; see the form guide)

Issued by

Manitoba Families – Disability and Health Supports Unit

Format

PDF

Language

English

Main medical report used by the Disability Adjudication Unit to decide whether an ODSP applicant meets the definition of a person with a disability.

Completed by

Physician, NP, registered nurse, psychologist or psychological associate, or optometrist

Issued by

ODSP (MCCSS) - Disability Adjudication Unit

Format

Online portal or EMR

Language

English and French

Describes how the applicant's impairment restricts activities of daily living; required for the ODSP disability decision.

Completed by

Physician, NP, RN, psychologist or psychological associate, optometrist, OT, physiotherapist, chiropractor, audiologist, speech-language pathologist, or social worker

Issued by

ODSP (MCCSS) - Disability Adjudication Unit

Format

Online portal or EMR

Language

English and French

Medical review of an existing ODSP recipient: updates the conditions identified at the original disability determination.

Completed by

Physician, NP, RN, psychologist or psychological associate, or optometrist

Issued by

ODSP (MCCSS) - Disability Adjudication Unit

Format

Sent for each case

Language

English and French

Covers conditions not listed in Part A during an ODSP medical review.

Completed by

HSR: physician, NP, RN, psychologist or psychological associate, or optometrist. ADL: also chiropractor, physiotherapist, OT, social worker, audiologist, or SLP.

Issued by

ODSP (MCCSS) - Disability Adjudication Unit

Format

Sent for each case

Language

English and French

Health professional confirms the medical conditions that qualify an OW or ODSP recipient for the monthly Special Diet Allowance.

Completed by

Physician (CPSO), RN(EC)/nurse practitioner, registered dietitian, registered midwife (only for inadequate lactation or when breast-feeding is contraindicated), or traditional Aboriginal midwife

Issued by

Ontario Works / ODSP (MCCSS)

Format

Sent for each case

Language

English and French

Demande de prestations pour soins de la vue (circonstances exceptionnelles)

Provider pre-authorization request for medically necessary vision items not on the social assistance vision care fee schedule (e.g., medically necessary contact lenses).

Completed by

Vision care service provider (e.g., optometrist or optician) registered as a supplier

Issued by

ODSP / Ontario Works (MCCSS)

Format

Fillable PDF

Language

English and French

Prestation pour prothèses auditives du POSPH (cas exceptionnels)

Pre-authorization request for hearing-aid items or services outside the standard ODSP hearing aid benefit because of exceptional circumstances.

Completed by

Registered Assistive Devices Program (ADP) hearing aid authorizer only (e.g., audiologist)

Issued by

ODSP (MCCSS)

Format

Fillable PDF

Language

English and French

Programme ontarien de soutien aux personnes handicapées (POSPH) Demande de Prestations obligatoires pour les nécessités spéciales

Confirms an ODSP recipient's medical need for medical transportation (appointments, addiction recovery groups, mental-health therapy) and for diabetic or surgical supplies, dressings, items and devices.

Completed by

Physician, NP, RN, OT, physiotherapist or physician assistant licensed in Ontario; psychologists may complete only the Medical Transportation section

Issued by

ODSP (MCCSS)

Format

Fillable PDF

Language

English and French

Rapports de réévaluation des différentes conditions médicales pour l'admissibilité au SEH

Condition-specific reports used to re-assess a child's continued eligibility for the SEH: physical impairments; food allergies; hearing; mental function disabilities including language disorders.

Completed by

Health professional (member of a professional order who assessed or saw the child in the last 12 months)

Issued by

Retraite Québec

Format

PDF

Language

English and French

Demande de supplément pour enfant handicapé – Partie de la professionnelle ou du professionnel

Health professional's assessment of a child under 18 whose impairment or mental-function disorder significantly limits daily activities for at least a year, for the Supplement for Handicapped Children (SEH) paid with the Family Allowance.

Completed by

Health professional who knows the child best, is a member of a professional order and assessed or saw the child in the last 12 months (physician, psychologist, speech-language pathologist, OT, physiotherapist, audiologist, optometrist, etc.)

Issued by

Retraite Québec

Format

Fillable PDF

Language

English and French

Medical Certificate

For last-resort assistance recipients: certifies pregnancy and the need for medical transport (prenatal/postnatal), and requests medically justified special benefits (e.g. prostheses/orthoses, orthopedic shoes, home hemodialysis, medical transport, other medical needs).

Completed by

Physician, IPS or midwife (pregnancy and prenatal/postnatal transport); physician, dentist or IPS (special medical benefits)

Issued by

MESS

Format

Fillable PDF

Language

French

Medical or Psychosocial Assessment Report

Documents a person's diagnosis and functional limitations (temporary, prolonged or permanent) so the ministry can recognize health-related employment constraints for last-resort assistance (Social Assistance or Social Solidarity Program).

Completed by

Physician, specialized nurse practitioner, psychologist, social worker, or couple and family therapist

Issued by

MESS

Format

Fillable PDF

Language

French

Medical evidence for a social assistance applicant or client (18+) seeking certification as 'disabled' by the Medical Advisory Board, which opens the Extended Benefits Program.

Completed by

Physician or specialist ('appropriate practitioner' per policy)

Issued by

NB Social Development

Language

English and French

Eye examination report used to certify a social assistance applicant or client as legally blind (Extended Benefits Program).

Completed by

Ophthalmologist or optometrist (policy: 'confirmed to be legally blind by an ophthalmologist or optometrist')

Issued by

NB Social Development

Language

English and French

Hearing examination report used to certify a social assistance applicant or client as deaf (Extended Benefits Program).

Completed by

'Appropriate practitioner' (the policy doesn't name the profession)

Issued by

NB Social Development

Language

English and French

Physician's report stating a social assistance applicant or client can't work for 6 months or more (or is 7+ months pregnant). It sets the Transitional Assistance rate and household-income exemptions, and 24 months of reports support a Long-Term Health Needs designation.

Completed by

Physician

Issued by

NB Social Development

Language

English and French

Documents a disability or chronic medical condition of an ESIA applicant, recipient or dependent. Used to decide basic and special needs, such as the Standard Household Rate - Enhanced - Medical and the $324/month Disability Supplement, and participation in employment services.

Completed by

Qualified medical practitioner or nurse practitioner (manual also refers to 'other medical professionals')

Issued by

NS Opportunities and Social Development (ESIA)

Language

English

Medical report required with every Disability Support Program (DSP) application; Care Coordinators may also request updated reports for participants or for capacity-to-consent decisions.

Completed by

Attending physician or nurse practitioner familiar with the applicant and their medical history

Issued by

NS Opportunities and Social Development (Disability Support Program)

Language

English

Health practitioner's request for ESIA to fund a prescribed item or service not otherwise covered (e.g. massage therapy, acupuncture, chiropractic, periodontal), with evidence of diagnosis, alternatives tried and efficacy.

Completed by

Health practitioner licensed in NS as a physician, dentist or nurse practitioner

Issued by

NS Opportunities and Social Development (ESIA)

Language

English

Practitioner report on medical conditions, employability and disability (impact on ADLs/IADLs). Used to establish eligibility for AccessAbility Supports and, given its employability section, likely other social programs.

Completed by

Health care practitioner (medical practitioner)

Issued by

PEI Social Development (form header: Department of Social Development & Housing; now Social Development and Seniors)

Format

PDF

Language

English

Formulaire D - Évaluation de l'incapacité

Medical confirmation of disability for the Income Assistance for Seniors and Persons with Disabilities program; listed with the Income Assistance forms.

Completed by

Medical practitioner or nurse practitioner (Section 2); a registered nurse licensed in the NWT only if there is no access to an MD/NP within 3 months (Section 3)

Issued by

NWT Education, Culture and Employment - Income Security Programs

Format

Fillable PDF

Language

English and French