Mental-health-specific attending physician questionnaire for a disability claim.
- Completed by
- Attending physician
- Issued by
- Blue Cross Ontario & Québec (Canassurance)
- Format
- Fillable PDF
- Language
- English
Blue Cross Short Term Disability APS (Canassurance)
Blue Cross (Canassurance) uses this two-page statement for the physician's part of a short term disability claim. Page 1 covers diagnosis, key dates, hospitalization, treatment and prognosis, while page 2 is needed only when the absence may exceed 4 weeks. The claim package, including this statement and the medical file, must reach the insurer within 90 days of the onset of disability.
Who completes it
The physician, or a nurse practitioner where applicable, completes the questions on pages 1 and 2 and signs with their specialty. The patient completes the plan member information and consent at the top of page 1.
Submitting and payment
- How to submit it
- Blue Cross's claimant's guide lists mail, fax and email contacts for its Claims, Life and Disability Insurance department, and Blue Cross also offers a secure online document submission form. The claim must reach the insurer within 90 days of the onset of disability.
- Who pays
- A notice on the form states that the patient is responsible for any fees related to its completion.
Good to know
- If the patient has returned to work, or is expected to within 4 weeks of the last date worked, complete page 1 only and sign the end of the form.
- Page 1 asks whether the condition involves an occupational illness or injury or an auto accident, plus the delivery date and type for childbirth claims.
- For longer absences, page 2 covers prior treatment, symptoms, restrictions and limitations, complications, treatment compliance and any concerns about the patient's ability to manage their own affairs.
- Attach relevant test results, consultation reports and clinical notes; unattached test results are read as tests not performed, and genetic test results should not be provided.
Get the official form
Download the current version from the source each time; forms change without notice.
Attending Physician’s Statement - Short Term Disability Claim
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Do I need to fill in page 2 of the Blue Cross short term disability statement?
Only for absences expected to be greater than 4 weeks. If your patient has returned to work, or is expected to return within 4 weeks of the last date worked, the form says to complete page 1 only and sign the end of the form. Otherwise complete pages 1 and 2 in full.
What is the deadline for a Blue Cross short term disability claim?
Blue Cross states that the claim must be submitted to the insurer within 90 days of the onset of disability, and that claims received after that may be denied. The claimant's guide recommends attaching the medical file, including the doctor's notes, to the physician statement to speed up processing.
Who pays for the Blue Cross short term disability attending physician statement?
The patient. A notice on page 1 and the patient's consent both state that the patient is responsible for any fees related to completing the form. Blue Cross's claimant's guide adds that some physicians charge to complete it and provide copies of documents, and these fees are the claimant's responsibility.