Industry initial medical statement used for Empire Life group short- and long-term disability claims.
- Completed by
- Attending physician or other medical provider
- Issued by
- Empire Life
- Format
- Fillable PDF
- Language
- English
Empire Life GRP-5008: Request for Drug Substitution
Empire Life uses this two-page request when a group plan member needs a drug substitution approved under the Extended Health Benefit provisions. It applies after trials of at least two lower-cost interchangeable drugs for the same condition, with satisfactory medical evidence of an adverse reaction to their ingredients. The completed form is returned to Empire Life's Group Health Claims department.
Who completes it
The patient or employee completes and signs Section 1, including the authorization; the prescribing healthcare professional completes Section 2 across both pages and signs with their professional designation.
Submitting and payment
- How to submit it
- The form's return instructions give a mailing address for Empire Life Group Health Claims in Kingston, Ontario; no fax or online channel is printed on it.
- Who pays
- The patient section states that the patient is responsible for any fees related to completing the form.
Good to know
- Eligibility requires trials with at least two lower-cost interchangeable drugs for the same condition and satisfactory medical evidence of an adverse reaction to ingredients in those drugs.
- If only one lower-cost alternative exists for the prescribed drug, Section 2 has a separate space to indicate this instead.
- For each drug that caused a reaction, the prescriber lists the drug name, result, reaction and date, then the drug requested for substitution with dosage and frequency.
- The prescriber also gives the reason for the request, current results and an estimated end date. The current version is GRP-5008-EN, revised 08/26.
Get the official form
Download the current version from the source each time; forms change without notice.
Request for Drug Substitution
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 can complete Empire Life's Request for Drug Substitution?
Section 2 is for the prescribing healthcare professional, who signs it and records their professional designation, address, phone and fax. The employee or patient completes and signs Section 1, and a parent or legal guardian signs for a child where applicable.
What evidence does the Empire Life drug substitution form ask for?
It asks whether the patient had an adverse drug reaction to ingredients in at least two lower-cost interchangeable treatments for the same condition. The prescriber lists each drug tried with its result, reaction and date, then the requested drug, current results, the reason for the request and how long the substitution is needed.
Who pays for completing the Empire Life drug substitution form?
The patient. In Section 1, the patient confirms they are responsible for any fees related to completing the form, alongside their consent for Empire Life to exchange medical information with its agents and service providers to handle the request and adjudicate claims.