Alberta Blue Cross copy of the industry initial medical statement for disability claims.
- Completed by
- Attending physician or other medical provider
- Issued by
- Alberta Blue Cross
- Format
- Fillable PDF
- Language
- English
Alberta Blue Cross Critical Illness APS (ABC 55087)
Alberta Blue Cross uses this statement for the doctor's part of a critical illness benefit claim under a group or personal plan. It asks for diagnosis dates and history, hospital and surgical treatment, objective and subjective findings, effects on activities of daily living and a prognosis framed against the plan's list of critical illnesses and conditions, with supporting test results attached.
Who completes it
The doctor completes Section 2 (attending physician statement), identifying as attending physician, consulting specialist or other, and signs the Section 3 notice with specialty and stamp. The employee (plan member) completes Section 1, including the claimant's details if the claimant is not the plan member.
Submitting and payment
- How to submit it
- The plan member is responsible for submitting the completed form, together with the employee statement, directly to Alberta Blue Cross Life & Disability Services by mail or fax.
- Who pays
- The plan member is responsible for accepting any charges for completing the form, as printed at the top of the statement.
Good to know
- Section 2 asks for the date symptoms first appeared, the date of first treatment, diagnostics or consultation, and the date of last treatment for the illness.
- If applicable, rate cardiac functional capacity on the Canadian Cardiovascular Society scale from Class I (no limitations) to Class IV (complete limitations) and forward stress test and angiogram results.
- Describe how the illness affects eating, dressing, bathing, ambulation and toileting, and whether the patient is competent to endorse cheques and direct the use of proceeds.
- The claim also needs the critical illness claim form for a group plan (55095) or for a personal plan (55237).
Get the official form
Download the current version from the source each time; forms change without notice.
Attending Physician Statement – Critical Illness Benefit
Fill it with Vero
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.
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.
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Frequently asked questions
Who pays for the Alberta Blue Cross critical illness physician statement?
The plan member. The instructions at the top of the form state that the plan member is responsible for submitting the completed form and accepting any charges for its completion. The plan member also submits the employee statement, and both go directly to Alberta Blue Cross Life & Disability Services.
What attachments does Alberta Blue Cross want with the critical illness APS?
The form asks you to summarize the patient's medical history and attach copies of tests administered, including the results of relevant clinical findings. For cardiac claims, it asks you to forward results of stress tests, angiograms and similar investigations along with the Canadian Cardiovascular Society functional class.
Is the Alberta Blue Cross statement for group or personal critical illness plans?
Both. The attending physician statement (ABC 55087) supports critical illness benefit claims under a group plan, filed with claim form 55095, or a personal plan, filed with claim form 55237. Section 1 also records the claimant's name, relationship and birth date when the claimant is not the plan member.