The harmonized medical form Canada's life and health insurers use to start a short- or long-term disability claim; several carriers list it as the Attending Physician's Statement. You meet it when a patient with group, individual or creditor disability coverage stops work for a medical reason. The patient fills Section 1, you complete Section 2, and the patient sends it to their insurer with the insurer's own claim forms.
The attending physician or other applicable medical provider completes Section 2, Medical Statement, ticking family physician, consulting specialist or other. The patient completes Section 1, Patient Information and Consent; the insurer's separate plan member and employer statements are completed by the patient and the employer or plan sponsor.
Completed by the patient before you start: contact details, date of birth, employer, contract or policy and certificate numbers, date last worked, actual or expected return-to-work date, current medications with dosage and frequency, height, weight and dominant hand. The patient names the insurer and signs an authorization to release consultation reports, clinical notes, test results and hospital records, excluding genetic test results. Check that it is signed and dated: the consent states the claim cannot be assessed without it.
Tick family physician, consulting specialist or other, and complete the section to the best of your knowledge. Give the primary diagnosis and any secondary diagnoses or complications; for childbirth, the expected or actual delivery date and whether it was vaginal or by C-section. Then say whether the condition stems from an occupational illness or injury, a motor vehicle accident or another accident (with the date), whether you recently completed other disability forms for this patient and for whom (another insurer, CPP, QPP, workers' compensation), your first visit for this condition and the first date of work absence.
List special programs, therapies and medications not already noted by the patient in Section 1, how often you see the patient (weekly, monthly or other) and the dates of the last and next visits. Record any past treatment for the same or a similar condition, with date and provider, and whether the patient is following the recommended treatment program, with details. Rate the response so far as complete, partial, none or too soon to tell, and explain any plan to change or augment treatment.
Answer whether the patient is or was hospitalized, whether future hospitalization is planned and whether there was or will be day surgery. Give admission and discharge dates and the institution for up to three stays, or attach the admission, discharge or operative reports, plus the date and description of any surgery. This is the stopping point for short claims: if the patient has returned to work or the disability will last under 4 weeks, sign the end of the form; otherwise complete every page.
Attach copies of all relevant test results and investigations, consultation reports and clinical notes. The form warns that if results are not attached, the insurer will interpret this as tests not having been performed, and it asks you not to send genetic test results. List pending tests with dates and descriptions. If no consultation report is attached, say whether the patient will see a specialist for this condition, with the specialist's name, specialty and appointment date.
Describe the patient's symptoms, including their history, severity and frequency, and tick whether they have improved, not changed or retrogressed to date. The next section asks you to base the patient's restrictions on these clinical findings and observations, so this is where the clinical basis for those restrictions belongs.
Based on your clinical findings and observations, describe the patient's current cognitive and/or physical restrictions and limitations. Then answer whether any licence the patient holds has been restricted or revoked because of the condition (date and type of licence), whether the patient can manage their own affairs, and whether other factors may affect the expected recovery period and return-to-work goals: workplace, social or family, financial or legal, personality issues, addiction or other, with an explanation.
Give the prognosis for improvement and/or recovery and describe the return-to-work goals you have discussed with the patient. Then print your name, specialty and licence or registration number, address, telephone, fax and email, and sign and date the form. A notice above the signature block reminds you that the statement goes into the insurer's or plan administrator's benefits file, where the patient or authorized third parties might see it.
Download the current version from the source each time; forms change without notice.
Initial Disability Insurance Medical Statement
Déclaration médicale initiale pour l’assurance invalidité
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.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Canada Life links straight to the CLHIA PDF and RBC Insurance points claimants to CLHIA's site. Sun Life, Manulife, Desjardins, Medavie Blue Cross, Equitable Life, Empire Life, The Co-operators, Wawanesa Life and Alberta, Saskatchewan and Manitoba Blue Cross publish branded copies. The federal public service disability plans (Sun Life, iA Financial Group) use it, and CIBC, RBC and TD creditor-insurance claim packages include it.
No. CLHIA says insurers are moving to one harmonized medical form that starts both short- and long-term disability claims, after earlier cutting their many medical forms down to four. For the federal Public Service Disability Insurance Plan, it replaced three condition-specific Attending Physician Questionnaires. Some insurers and plan sponsors may take up to a year to switch fully, so older company forms can still arrive.
The patient. The first page states that the patient is responsible for any fees related to completing the form, and the consent the patient signs in Section 1 says the same. Insurer-branded copies, such as those from Desjardins, Equitable Life and the Blue Cross plans, print the same notice, and Sun Life's claim guide says the patient pays any fee the doctor charges.
Possibly. The notice above the signature block says the statement is kept in a life, health or disability benefits file with the insurer or plan administrator and might be accessible by the patient, by third parties granted access, or by those authorized by law. The patient's consent covers consultation reports, clinical notes, test results and hospital records, but not genetic test results.