Albertans applying for Assured Income for the Severely Handicapped (AISH) or the Alberta Disability Assistance Program (ADAP) need a health professional to complete this 11-page report alongside their DS2444A application. It documents diagnoses, functioning, treatment and prognosis so the ministry can judge how the condition affects employment: AISH covers disabilities that permanently prevent work, ADAP those that substantially impede it. It replaced the former AISH Part B medical report.
A health professional registered in Alberta, normally the applicant's physician or nurse practitioner, completes and signs the whole report, with help from nurse practitioners, specialists or allied health professionals if needed. The applicant completes the separate DS2444A application.
Confirm the applicant's name, any different last name on the birth certificate, preferred first name, date of birth, gender, Alberta Personal Health Number and phone. Asterisked fields are mandatory: an answer is required for the application to be complete. The form opens with two notes worth reading: careful completion is integral to applicants receiving the right supports, and the report is not the only factor the ministry weighs.
Question 1 asks whether you are a health professional registered in Alberta, with your discipline and registration number; the report must be completed by one. Then state how long you have been treating the applicant, when you last treated them, and how often you see them on average, from once a week to once a month or more. This tells the ministry about your history treating the conditions relevant to the application.
List up to three main diagnoses plus additional relevant ones, each with month and year of onset and a DIA Medical Code from the reference chart (for example 53 for affective disorder or 40 for low back pain syndrome) or a DSM V code. Then give details for each diagnosis, including etiology, classification or stage and its specific symptoms, and a medical history covering chronology, progression, impairment, duration and restriction for each condition. Record referrals with consultation reports, other evidence such as diagnostics and lab tests, and relevant hospital admissions, marking which documents are attached.
Rate 29 activities (questions 11 to 39) as DK (don't know), 0 (no limitation), 1 mild, 2 moderate or 3 severe, grouped under mobility, cognitive function, personal care, independent living skills and social function. Items range from transferring, sitting and stair climbing to reading, bladder control, meal preparation, managing finances and maintaining personal safety. Describe a limitation wherever the rating needs explaining. Question 40, which is mandatory, asks you to describe the symptoms behind the cumulative level of impairment, and relevant assessment reports can be attached.
Questions 41 to 67 use the Intellectual and Emotional Wellness Scale (IEWS) to rate symptoms from 0 (not present) to 3 (severe, a barrier to well-being), or DK. Domains cover mental and emotional states, thought and perception, cognitive function, behaviour, orientation, speech, physical and somatic changes such as sleep or appetite, and safety, including suicidal ideation, plans or attempts. Question 68, also mandatory, asks you to summarize how these symptoms add up to the applicant's overall impairment.
List relevant medications and their effect on functioning (question 69), or attach a medication list. Describe the treatment history and results with timeframes, and the current medical plan: when it started, the anticipated results and how often it is reviewed. If no treatment has been tried or planned, explain why. Questions 72 and 73 ask whether the applicant follows the treatment plans of their primary health professional and of other professionals, with an explanation if not. Finish with any further treatment anticipated, its expected results and timeframe.
Question 75 asks whether the condition is likely to be temporary (will improve with further treatment, with an estimated duration), episodic (describe the frequency, length and severity of episodes and the total duration if known), permanent (not expected to change or improve with treatment) or undetermined (unclear whether it will improve, with an explanation). AISH policy looks for a disability that permanently prevents employment, while ADAP covers one that substantially impedes employment continuously or episodically.
Question 76 is open space for anything else relevant to the applicant's condition that the ministry should consider in determining eligibility. Use it, or added pages, when other answers run out of room. Attach reports, assessments and other documentation from you, consulting specialists and allied health practitioners that relate to the conditions, diagnoses and impairments, but do not send the entire medical record.
Print your name and give your CPSA or CRNA registration number, phone, office address and the date, then sign. By signing you confirm that you completed or approved the information and that the report and attached documents contain medical reports, clinical findings and your medical opinion at this time. The report must be completed by a health professional registered in Alberta.
Download the current version from the source each time; forms change without notice.
Disability Income Assistance Medical Report
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
Sources for this guide
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It must be completed and signed by a health professional registered to practise in Alberta, or the application will not be processed. The certification asks for a CPSA or CRNA registration number. You can complete it yourself or with help from nurse practitioners, specialists and allied health professionals, and attach their reports and assessments.
The applicant pays you directly. The fee is the equivalent of Schedule of Medical Benefits code 03.04A, or the matching specialty code, for the examination, plus a report fee agreed with the Alberta Medical Association. For applicants on Income Support the government may cover the cost, and you will receive an expense approval letter from Income Support or from the applicant.
The DS2444B is an encrypted fillable form that Alberta says cannot be opened in a web browser or used on a mobile device. Save the file to your computer and open it in Adobe Acrobat Reader. The read-only copy posted on the AISH website is marked for information only and should not be submitted.
No. The form notes that the application is an important document but not the only factor: Assisted Living and Social Services decides eligibility after reviewing all pertinent circumstances, including medical, financial, age and residency criteria. Your role is to give an accurate picture of the condition, functioning, limitations and prognosis.