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Blue Cross APS Questionnaire: Mental Health Conditions

Blue Cross (Canassurance) lists this questionnaire with its initial claim forms for disability insurance, for claims involving a mental health condition. In CLHIA format, it asks the doctor to rate how the condition affects 11 areas such as memory, concentration and mood, and to document medications, psychological and other treatment, complicating factors, prognosis and return-to-work goals.

Who completes it

The doctor completes Section B, items 1 to 11, and signs it with their specialty. The patient completes Section A, including employer, plan contract and certificate numbers, last day worked, height, weight and consent.

Submitting and payment

How to submit it
Blue Cross says the disability claim must reach the insurer within 90 days of the onset of disability, and its claimant's guide asks that clinical notes, test results and specialist reports accompany the physician's form.
Who pays
The patient's consent in Section A states they are responsible for any fees, and Blue Cross's claimant's guide confirms physician fees for the form and copies are the claimant's responsibility.

Good to know

  • Section 3 rates impact on appearance, memory, energy, behaviour, decision making, socialization, concentration, speech, affect/mood, insight/judgement and self-criticism as none, mild, moderate or severe.
  • Psychological treatment (section 8) and concurrent physiological treatment such as physiotherapy (section 9) are listed separately, each with provider, start date, visit frequency and response.
  • Missing test results are interpreted as tests not performed; attach relevant results and consultation reports, but never genetic test results.
  • Section 5 also asks whether any licence held by the patient has been restricted or revoked because of the condition, and since when.

Get the official form

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

Attending Physician’s Questionnaire – Mental Health Conditions

Official pagePDF

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.

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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

When is the Blue Cross mental health questionnaire used?

Blue Cross lists this questionnaire with its initial claim forms for disability insurance, and the claimant's guide packages it with the short term disability attending physician's statement. The claim, including the physician's documents, must be submitted to the insurer within 90 days of the onset of disability, or it may be denied.

Who pays for the Blue Cross mental health questionnaire?

The claimant. The consent signed in Section A says the patient is responsible for any fees related to completing the form, and the claimant's guide notes that some physicians charge to complete it and provide copies of relevant documents, and that these fees are the claimant's responsibility.

Can the patient comment on what I write in the questionnaire?

Not on the form itself. Blue Cross's claimant's guide tells claimants not to write anything on, or amend, the doctor's notes on the attending physician's statement. A claimant who wants to comment must use a separate sheet, such as the Notes pages at the end of the guide.