Try for free

Nova Scotia ESIA Medical Assessment Form

Nova Scotia's Employment Support and Income Assistance (ESIA) program uses this form when an applicant, recipient or dependent child has a disability or medical condition. Caseworkers rely on it to assess basic and special needs and participation in employment services, including the enhanced medical Standard Household Rate and the Disability Supplement. Both the medical professional and the applicant or recipient sign it.

Who completes it

A qualified medical practitioner or nurse practitioner completes and signs the medical portion, and the policy manual also accepts other medical professionals for some benefits. The applicant or recipient signs the form as well.

Submitting and payment

How to submit it
The form is handled through the ESIA caseworker as part of the program's required documentation. Re-assessment may be needed at an interval the medical professional indicates or when circumstances change.

Good to know

  • For the enhanced Standard Household Rate, the form must show a disability or a chronic mental, cognitive or physical condition that limits participation in employment services (Policy 7.2.1(a)).
  • The Disability Supplement needs a disability, or a chronic medical condition that prevents or will prevent employment for at least 12 consecutive months (Policy 8.2.6).
  • Medical documentation may not be needed if the person receives or is eligible for CPP Disability, employer long-term disability, the Disability Tax Credit, workers' compensation disability or the Canada Workers Benefit disability supplement.
  • The form also supports the barrier-free access allowance, when a terminal illness or physical disability means the person needs barrier-free access to, from or within their home.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Assessment

Official page

Get the note ready with Vero

This form isn’t published as a fillable PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.

See how Vero Scribe works

How this list is checked

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can sign the ESIA Medical Assessment?

The required-documents list says it is signed by a qualified medical practitioner or nurse practitioner and by the applicant or recipient. For the Disability Supplement, the manual says assessments must be completed by a physician, nurse practitioner or other medical professionals.

How often does the ESIA Medical Assessment need updating?

Re-assessment of a recipient's medical condition may be required at an interval the medical professional indicates, or when circumstances change. The Disability Supplement stops when medical documentation shows the condition no longer prevents employment, or when the person becomes employed.

Is a special diet requested on the ESIA Medical Assessment?

Special diets are handled separately under Policy 8.2.34. Documentation from a medical doctor, nurse practitioner or registered dietitian must give the diagnosis, the reason for the diet, the type of diet and how long it is needed, and it is required before the allowance is approved.