Revenu Québec's certificate of a severe and prolonged impairment in mental or physical functions. It supports the line 376 impairment amount for adults, higher childcare or children's activities credits for a child with such an impairment, and the caregiver tax credit. Patients need it the first time they claim; you complete Parts 2 to 4, plus Part 5 for a caregiver claim, and Revenu Québec decides eligibility.
A physician or specialized nurse practitioner can evaluate any ability; optometrists (vision), audiologists (hearing), speech-language pathologists (speech), physiotherapists (walking), psychologists (mental functions) and occupational therapists (walking, eating, dressing) only within their field. The person or their legal representative completes Part 1: identification, the request to adjust past returns, consent and signature.
The person or their legal representative enters identification details, says whether Revenu Québec should adjust past returns (generally the three previous years) if the certificate is accepted, ticks the consent box and signs. The consent authorizes the health professionals named on the form to send Revenu Québec the information it needs and allows Revenu Québec to discuss it with them. You complete the rest; the self-evaluation questionnaire on page 10 is not sent.
Compare the patient with a person of the same age without an impairment, and answer only for abilities your profession may evaluate. Vision (physician, specialized nurse practitioner, optometrist): blind, or corrected acuity of 20/200 (6/60) or less, or a visual field of 20 degrees or less, in the better eye. Speech (with speech-language pathologists) and hearing (with audiologists) ask whether the patient can be understood, or follow a conversation without lip-reading, in a quiet setting. Each yes needs the year it began.
Walking (also occupational therapists and physiotherapists): unable to walk about 100 metres on level ground, or only with severe leg pain, frequent loss of balance or stopping for breath on mild exertion. Elimination (physicians and specialized nurse practitioners only): needing help, bowel irrigation, incontinence briefs or intermittent catheterization; an uncomplicated ostomy may not qualify. Eating and dressing (also occupational therapists) exclude shopping for food or clothing and, for eating, food preparation required by a dietary regime.
Physicians, specialized nurse practitioners and psychologists assess adaptive functioning, attention, concentration, goal setting, judgment, memory, perception of reality, problem-solving, regulation of behaviour and emotions, and verbal and non-verbal comprehension. The form treats these functions as markedly restricted when the patient lacks the mental capacity to manage personal affairs or see to personal care without supervision. It also notes that diagnosed ADHD managed with medication or other strategies may not count as markedly restricted.
Use this when no single ability is markedly restricted but the patient is significantly restricted in at least two basic activities, or in vision and at least one activity, all or substantially all of the time, the restrictions occur together, and their combined effect equals one marked restriction. Tick each restricted ability and give the year. The form's example is multiple sclerosis with constant fatigue, depression and balance problems. Occupational therapists may certify only when the restrictions involve walking, eating or dressing alone.
Physicians and specialized nurse practitioners only. For type 1 diabetes from 2021 on, answer line 38 alone: the year therapy started. Otherwise, the therapy must be needed because of a chronic disease, prescribed by a physician or specialized nurse practitioner, essential to sustain a vital function, given at least twice a week and take 14 hours or more a week, counting travel, appointments and recovery. Describe the prescribed therapy; exercise, diet, hygiene or medication programs that would benefit people without a chronic disease do not count.
Describe the impairment and the disability it causes, attaching a sheet if you need more space. The form defines each restriction by what the patient cannot do even with therapy, devices and medication, so this box is where that effect on daily activities is spelled out. Revenu Québec may write to any person named on the form for more information about the impairment and its effects.
Question 41 asks whether the impairment has lasted at least 12 consecutive months or, if it began during the year, can reasonably be expected to last that long; without a yes, the impairment cannot be certified. Question 42 asks whether the condition can be expected to improve so that the restriction, cumulative effect or need for essential therapy ends (yes, no or unsure), and question 43 asks for the probable or actual year of improvement.
Tick your profession, then give your name, provincial licence or professional order membership number, office address, telephone, signature and date, certifying that the information in Parts 2 and 3 is accurate and complete. The fillable version can be signed electronically. Expect possible follow-up: the patient's consent in Part 1 allows Revenu Québec to discuss the form with the health professionals named in it.
Complete only when someone claims the caregiver tax credit. Section 5.1 (2018 and later), completed by the professional who certified the impairment, asks whether the patient needs assistance with a basic activity of daily living because of the impairment, and since what year. Section 5.2 (years before 2020), for physicians and specialized nurse practitioners, asks whether the patient is unable to live alone. Sign the separate certification in 5.3.
Download the current version from the source each time; forms change without notice.
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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Physicians and specialized nurse practitioners can certify any ability. Other professionals certify only within their field: optometrists for vision, audiologists for hearing, speech-language pathologists for speech, physiotherapists for walking, psychologists for mental functions, and occupational therapists for walking, eating and dressing, including their cumulative effect. Elimination and essential therapy are reserved to physicians and specialized nurse practitioners.
Usually. For Québec's impairment amount, Revenu Québec accepts a copy of the CRA's T2201 instead. It requires TP-752.0.14-V when eligibility rests on essential therapy needed at least twice a week for 14 or more hours a week, and for the caregiver tax credit, where the form confirms the care receiver needs assistance with a basic activity of daily living.
Even with appropriate therapy, medication and devices, the patient is unable to carry out the activity all or substantially all of the time (at least 90% of the time), or needs an inordinate amount of time to do it. Revenu Québec generally treats considerably longer, for example three times the average time for someone the same age without an impairment, as inordinate.
For 2021 and later years, Revenu Québec considers that a patient receiving essential therapy for type 1 diabetes meets the essential therapy requirements. A physician or specialized nurse practitioner answers only line 38 in section 2.10.1, the year therapy began. For earlier years, type 1 diabetes is assessed under the general essential therapy test in section 2.10.2.