Canada Life uses this one-page physician assessment to support coverage of a positive airway pressure machine under a workplace health plan. The physician confirms whether it is an initial or replacement device, the sleep study and diagnosis, and, for BPAP, VPAP or ASV devices, the clinical criteria that support them. The patient attaches the form and receipts or an estimate to their health claim.
The physician completes the whole form and certifies it with their name, registration number and designation. The patient adds it, with receipts or an estimate, to their Canada Life health claim form.
Download the current version from the source each time; forms change without notice.
Positive Airway Pressure Machine Assessment Form
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.
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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Only for an initial BPAP, VPAP or ASV device. Section 2 asks you to check supporting criteria, such as pressures of 15 cm H2O or more, nocturnal hypercapnia or desaturation on CPAP, intolerance of CPAP despite an adequate trial, obesity hypoventilation or central or mixed sleep apnea, and to provide supporting results.
They must apply first. The form instructs residents of Saskatchewan, Manitoba and Ontario to apply for coverage through the appropriate provincial health program before submitting a claim or estimate to Canada Life. The completed assessment and receipts or estimate are then attached to the claim form and sent to the Benefit Payment Office shown on it.
The physician indicates whether the patient had a Level 1 (lab or clinic) study, a Level 3 home study or another type, attaches a copy of the diagnostic report and any titration, and states whether the study confirms mild OSA, moderate or severe OSA, or another diagnosis.