Federal medical forms for clinicians in Canada

Certificat pour le crédit d'impôt pour personnes handicapées

A medical practitioner certifies the effects of the patient's impairment so the CRA can decide eligibility for the disability tax credit. DTC approval also gives access to the Canada Disability Benefit, the Child Disability Benefit and the RDSP.

Completed by

Medical doctor or nurse practitioner (all impairments); optometrist (vision); audiologist (hearing); occupational therapist (walking, feeding, dressing); physiotherapist (walking); psychologist (mental functions); speech-language pathologist (speaking)

Issued by

CRA

Format

Fillable PDF

Language

English and French

Rapport médical pour prestations d'invalidité du Régime de pensions du Canada

The treating doctor or NP reports the applicant's medical conditions, functional limitations, treatment, employment situation and prognosis for a CPP disability benefit application (severe and prolonged, non-terminal).

Completed by

Physician or nurse practitioner

Issued by

Service Canada

Format

Fillable PDF

Language

English and French

Déclaration d'incapacité - rapport du médecin

A physician declares that the patient could not form or express an intention to apply for CPP benefits, with start and end dates of incapacity, so an application can be treated as made earlier than the normal retroactivity limit.

Completed by

Physician (Social Security Tribunal decisions show nurse practitioners have also completed it)

Issued by

Service Canada

Format

Sent for each case

Language

English and French

A short updated medical report Service Canada asks the treating clinician to complete when it reviews whether a CPP disability beneficiary is still eligible.

Completed by

Treating health professional who receives the request (typically the physician or NP)

Issued by

Service Canada

Format

Sent for each case

Language

English and French

A short medical report Service Canada requests when a patient's disabling condition comes back, in connection with CPP disability benefits.

Completed by

Treating physician or NP who receives the request

Issued by

Service Canada

Format

Sent for each case

Language

English and French

Attestation médicale de maladie en phase terminale pour une demande de prestations d'invalidité en vertu du Régime de pensions du Canada

A short attestation by a doctor or NP that the applicant has a terminal illness, for fast-tracked CPP disability benefits.

Completed by

Physician or nurse practitioner

Issued by

Service Canada

Format

Fillable PDF

Language

English and French

Certificat d'incapacité - SV/RPC

Certifies that a person cannot manage their own affairs, so that a trustee, agency or institution can be appointed to receive and administer their OAS/CPP benefits.

Completed by

Medical professional: physician, registered nurse, nurse practitioner, psychologist or another listed professional. For seniors, designated non-medical professionals (social worker, lawyer, clergy) may also certify.

Issued by

Service Canada

Format

Fillable PDF

Language

English and French

Certificat médical pour les prestations de maladie de l'assurance-emploi

Attests that the patient cannot work for medical reasons, with the start date and expected duration of incapacity, for EI sickness benefits.

Completed by

Treating medical practitioner: medical doctor, nurse practitioner, or within their field a chiropractor, podiatrist, optometrist, psychologist, dentist or midwife; a registered nurse in isolated areas when no doctor is available

Issued by

Service Canada

Format

Fillable PDF

Language

English and French

Certificat médical pour des prestations de compassion de l'assurance-emploi

Certifies that a family member has a serious medical condition with a significant risk of death within 26 weeks and needs care or support, for EI compassionate care benefits (up to 26 weeks, shareable among caregivers).

Completed by

Medical doctor or nurse practitioner

Issued by

Service Canada

Format

Fillable PDF

Language

English and French

Certificat médical pour les prestations pour proches aidants de l'assurance-emploi

Certifies that an adult or child is critically ill or injured and needs care or support, with an estimated duration, for EI family caregiver benefits (up to 15 weeks for an adult, up to 35 weeks for a child under 18).

Completed by

Medical doctor or nurse practitioner

Issued by

Service Canada

Format

Fillable PDF

Language

English and French

VAC asks a health professional to complete the questionnaire for each claimed or entitled condition, to confirm the diagnosis and assess it against the Table of Disabilities for disability benefits (pain and suffering compensation or disability pension).

Completed by

Health professional authorized to diagnose within their scope. GP, specialist or NP for most conditions; physician assistants only in AB, SK, MB, NB, NS and PE. Also chiropractors (musculoskeletal), podiatrists (foot/toe), audiologists (hearing), psychologists and psychiatrists (mental health), dentists (dental), and ophthalmologists or optometrists (vision).

Issued by

VAC

Format

Fillable PDF

Language

English and French

Questionnaire médical : affections du genou

Documents the diagnosis and assessment of knee conditions for VAC disability benefits.

Completed by

Physician, NP or chiropractor; physiotherapists for assessment or reassessment only

Issued by

VAC

Format

Fillable PDF

Language

English and French

Questionnaire médical : Affections de la colonne dorsolombaire

Documents the diagnosis and functional assessment of thoracolumbar spine conditions for VAC disability benefits.

Completed by

Physician, NP or chiropractor; physiotherapists for assessment or reassessment only, not diagnosis

Issued by

VAC

Format

Fillable PDF

Language

English and French

Questionnaire médical : Affections psychologiques/psychiatriques

Documents the diagnosis and severity of psychiatric or psychological conditions (e.g., PTSD) for VAC disability benefit assessment.

Completed by

Psychiatrist; registered, licensed or associate psychologist; GP; or NP. Candidate psychologists only if co-signed. Psychotherapists and clinical or professional counsellors for assessment only. Social workers are not accepted.

Issued by

VAC

Format

Fillable PDF

Language

English and French

Questionnaire médical : Hypoacousie/Acouphène

Documents a confirmed diagnosis of hearing loss and/or tinnitus for VAC disability benefit assessment.

Completed by

Audiologist, physician or NP. Hearing instrument practitioners may be accepted for assessment only, if a qualified professional diagnosed the condition earlier.

Issued by

VAC

Format

Fillable PDF

Language

English and French

Rapport d'évolution de la psychothérapie

The treating psychologist's progress report to VAC on psychological treatment: DSM diagnoses, sessions and missed appointments, test results, objectives met, changes to the treatment plan, and recommended further sessions.

Completed by

Treating psychologist or mental health provider registered with Medavie Blue Cross

Issued by

VAC

Format

Fillable PDF

Language

English and French

Demande de prolongation du traitement

The treating provider asks for more VAC-funded treatment sessions beyond the yearly benefit-grid limits. The provider gives objective baseline measures, measurable goals and the reasons for more sessions.

Completed by

Treating health professional providing the VAC treatment benefit (the profession varies, e.g., physiotherapy-type services); the Veteran signs the certification

Issued by

VAC

Format

Fillable PDF

Language

English and French

Rapport du médecin examinateur

A medical examination report requested by VAC covering complaints, history, physical findings, special studies (when authorized by the VAC Medical Adviser or district authority), functional and psychosocial assessment, employability (restrictions, retraining potential) and prognosis.

Completed by

Examining physician (medical examiner) at VAC's request

Issued by

VAC

Format

Fillable PDF

Language

English and French

Évaluation du médecin de famille

A general medical assessment VAC requests from a client's family physician: reason for referral, review of body systems, lab results (chest x-ray, Hgb, FBS, BUN, electrolytes, urinalysis), mental status and competence to handle own affairs, current therapy, allergies, diagnoses and prognosis, for VAC's health care team.

Completed by

Family physician

Issued by

VAC

Format

Fillable PDF

Language

English and French

Questionnaire initial sur la santé mentale pour le Programme pour l'autonomie des anciens combattants

The treating mental health provider assesses whether a Veteran's mental health condition creates barriers to housekeeping, grounds maintenance, errands or meal preparation, and recommends Veterans Independence Program (VIP) assistance.

Completed by

Treating mental health service provider: psychologist, psychiatrist, social worker or other qualified health professional

Issued by

VAC

Format

Fillable PDF

Language

English and French

Questionnaire de suivi sur la santé mentale pour le Programme pour l'autonomie des anciens combattants

Follow-up reassessment by the treating mental health provider of a Veteran's continuing need for VIP assistance.

Completed by

Treating mental health service provider

Issued by

VAC

Format

Fillable PDF

Language

English and French

Rapport médical pour la Disposition applicable aux étudiants ayant une invalidité grave et permanente

A physician or NP assesses whether a student-loan borrower has a severe permanent disability that prevents substantially gainful work for life, so that Canada Student Loans, participating provincial loans and Canada Apprentice Loans can be cancelled.

Completed by

Licensed physician or nurse practitioner

Issued by

ESDC (Canada Student Financial Assistance Program)

Format

Fillable PDF

Language

English and French

Verifies a permanent, or persistent or prolonged, disability for first-time RAP-D applicants who have never received a PD or PPD grant, for Canada Student Loans and Canada Apprentice Loans.

Completed by

Licensed medical practitioner registered where the assessment is done, e.g., physician, nurse practitioner, audiologist, optometrist or psychologist

Issued by

ESDC (Canada Student Financial Assistance Program)

Format

Fillable PDF

Language

English and French

Rapport d'examen médical de l'aviation civile

The Civil Aviation Medical Examiner's report of an aviation medical examination, used to issue or renew aviation medical certificates for pilots, air traffic controllers and other licence or permit holders.

Completed by

Civil Aviation Medical Examiner (CAME) designated by Transport Canada only

Issued by

Transport Canada

Format

Fillable PDF

Language

English and French

Formulaire de déclaration de l'état de santé de la médecine aéronautique civile

A physician or optometrist reports to Transport Canada Civil Aviation Medicine a patient's medical condition that is relevant to aviation safety (e.g., in a pilot or air traffic controller).

Completed by

Physician or optometrist (any, not only CAMEs)

Issued by

Transport Canada

Format

Fillable PDF

Language

English and French

Déclaration médicale pour les licences et les permis nécessitant une catégorie 4 norme médicale

Self-declaration of medical fitness for permits that need a Category 4 medical certificate. For a student pilot permit (aeroplane) or a recreational pilot permit, a family physician countersigns Part B.

Completed by

Applicant; family physician countersigns Part B where required (student pilot permit for aeroplanes, recreational pilot permit)

Issued by

Transport Canada

Format

PDF

Language

English and French

Certificate a CAME issues after a telemedicine renewal of an aviation medical certificate. The holder keeps it with their medical certificate or Aviation Document Booklet.

Completed by

Civil Aviation Medical Examiner (CAME)

Issued by

Transport Canada

Language

English and French

Paper provisional marine medical certificate for a seafarer, issued while Transport Canada reviews the marine medical examination report.

Completed by

Marine Medical Examiner (designated)

Issued by

Transport Canada

Format

Sent for each case

Language

English and French

Medical report on fitness for marine pilots (national marine pilotage medical standard).

Completed by

Examining physician (likely a designated Marine Medical Examiner)

Issued by

Transport Canada

Format

Sent for each case

Language

Bilingual

Attending physician's statement for an initial long-term disability claim under the federal Public Service Management Insurance Plan (PSMIP).

Completed by

Attending physician or medical provider

Issued by

iA Financial Group (Public Service Management Insurance Plan)

Format

PDF

Language

English

Attending clinician's medical statement supporting an initial long-term disability claim under the federal Public Service Disability Insurance (DI) Plan, policy 12500-G.

Completed by

Attending physician (or applicable treating medical provider)

Issued by

Sun Life (federal Public Service Disability Insurance Plan)

Format

PDF

Language

English

Initial attending physician's statement for a Canadian Armed Forces member's SISIP long-term disability claim on release (Manulife group policy 901102).

Completed by

Treating physician

Issued by

SISIP Financial (Manulife)

Format

Fillable PDF

Language

English

Follow-up medical update requested on an existing SISIP LTD claim to assess continuing entitlement (Manulife group policies 901102/911104/911105).

Completed by

Attending physician

Issued by

SISIP Financial (Manulife)

Format

Fillable PDF

Language

English

The prescriber applies for a client receiving end-of-life care to get access to the NIHB end-of-life drug list.

Completed by

Prescriber

Issued by

Indigenous Services Canada (NIHB)

Format

Sent for each case

Language

English and French

The prescriber requests NIHB coverage for a drug not on the NIHB Drug Benefit List for a First Nations or Inuit client, with clinical justification.

Completed by

Licensed prescriber

Issued by

Indigenous Services Canada (NIHB)

Format

Sent for each case

Language

English and French

Prior approval for NIHB limited-use drug benefits that are covered only when set criteria are met.

Completed by

Licensed prescriber

Issued by

Indigenous Services Canada (NIHB)

Format

Sent for each case

Language

English and French

The practitioner requests emergency access to a drug not marketed in Canada for a specific patient with a serious or life-threatening condition.

Completed by

Treating practitioner

Issued by

Health Canada

Format

Fillable PDF

Language

English and French

The practitioner requests a non-marketed drug ahead of time for future emergency use when the patient is not yet identified, with a valid reason for needing it in advance.

Completed by

Practitioner (e.g., on behalf of a hospital or clinic)

Issued by

Health Canada

Format

Fillable PDF

Language

English and French

Mandatory report to Health Canada on the results of using a drug obtained through the SAP, including adverse reactions.

Completed by

Practitioner who received the drug

Issued by

Health Canada

Format

Fillable PDF

Language

English and French

Formulaire de demande d'accès spécial aux instruments médicaux

A health care professional applies for access to a medical device that is not licensed in Canada, for a patient, under the Medical Devices Special Access Program.

Completed by

Health care professional (must sign)

Issued by

Health Canada

Format

Fillable PDF

Language

English and French

Document médical autorisant la consommation de cannabis à des fins médicales

The health care practitioner's medical document supporting a patient's use of cannabis for medical purposes, so the patient can buy from a federally licensed seller or register with Health Canada for personal or designated production.

Completed by

Health care practitioner (as defined in the Cannabis Regulations)

Issued by

Health Canada

Format

PDF

Language

English and French

Used by enrolled NIHB mental health counselling providers for prior approval, exception requests for more hours, approval after services were given, and claims.

Completed by

Enrolled NIHB mental health counselling provider (e.g., psychologist, counsellor)

Issued by

Indigenous Services Canada (NIHB)

Language

English and French

Formulaire d'avis médical : dispenses relatives à la citoyenneté

The attending medical practitioner's opinion supporting a citizenship applicant's request to waive the language and knowledge (citizenship test) requirements and/or the oath because of a severe and prolonged medical condition.

Completed by

Attending medical practitioner: GP or family physician (CCFP), other physician specialist, psychologist or nurse practitioner

Issued by

IRCC

Format

Fillable PDF

Language

English and French

Rapport médical – Sommaire et données biométriques du client

Immigration medical examination (IME) record for all immigration categories, with client biodata, immigration information, IMM type, IME grading and the panel physician's declaration.

Completed by

IRCC-designated panel physician only

Issued by

IRCC

Format

Online portal or EMR

Language

English and French

Rapport médical

Paper version of the immigration medical examination report, including the laboratory requisition and report and the chest x-ray requisition section. Used only where eMedical is not available.

Completed by

Panel physician; panel radiologist (chest x-ray section)

Issued by

IRCC

Format

Sent for each case

Language

English and French

Formulaire pour l'évaluation des besoins de réétablissement

The panel physician assesses the medical and resettlement needs of refugee applicants examined overseas.

Completed by

Panel physician

Issued by

IRCC

Format

Online portal or EMR

Language

English and French

The panel physician confirms that counselling was given to an IME client who tested HIV-positive or disclosed HIV-positive status.

Completed by

Panel physician

Issued by

IRCC

Format

Online portal or EMR

Language

English and French

Cliente enceinte – Radiographie différée

Records that a pregnant IME client chose to defer the chest x-ray. eMedical generates a deferral letter with instructions for the client.

Completed by

Panel physician

Issued by

IRCC

Format

Online portal or EMR

Language

English and French