Doctor's medical report supporting an OMERS disability contribution waiver and/or disability pension.
- Completed by
- Member's doctor
- Issued by
- OMERS
- Format
- Language
- English
NB Teachers' & Judges' Disability Pension APS
New Brunswick teachers and Provincial Court judges applying for a disability pension need this attending physician's statement alongside the member application. The form is published by Vestcor, but the completed statement goes to Medavie Blue Cross Case Management Services rather than to Vestcor. The current version, dated February 2024, is a fillable PDF in English.
Who completes it
The patient completes Part 1, an authorization to release claim information to the benefits adjudicators and policyholder. The attending physician completes Part 2, eight sections from diagnosis to remarks.
Submitting and payment
- How to submit it
- Return the completed form to Medavie Blue Cross, Case Management Services, in Moncton, at the address printed at the end of the form.
- Who pays
- The form states that the patient is responsible for securing it and for any charge for its completion.
Good to know
- Attach copies of current X-rays, EKGs, laboratory data, consultation reports, hospital discharge summaries and clinical notes, as the form instructs in capital letters.
- Section 6 rates function on a four-level scale, from no limitation to severe limitation, and asks whether the patient is ambulatory, house, bed or hospital confined.
- For psychiatric conditions, Section 6 asks for a multiaxial assessment if available; Section 3 has a cardiac functional class (1 to 4) where applicable.
- Section 7 asks for prognosis, timeframe for medical recovery, other factors affecting recovery, and factors to consider in a return-to-work plan.
Get the official form
Download the current version from the source each time; forms change without notice.
Attending Physician's Statement – Application for Disability Pension
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
Which plans use the Vestcor attending physician statement?
The form covers disability pension applications under the New Brunswick Teachers' Pension Plan and under the Provincial Court Act and Provincial Court Judges' Pension Act. The member also files the Disability Pension Application for Teachers and Judges, the member's own part of the claim.
What treatment details does the form ask for?
Section 5 asks for visit frequency, current medications and dosages, surgery, hospitalizations with dates and facility, therapy by type and practitioner, any treatment for alcohol or drug use, future treatment plans, the patient's response, and whether they follow the recommended treatment.
Who pays for completing the teachers' disability pension statement?
The patient. The instructions say the patient is responsible for securing the form and for any charge for completing it, and the patient's signed authorization repeats that the charges are their responsibility. The completed form then goes to Medavie Blue Cross Case Management Services, not to Vestcor.