Physician statement accompanying an Alberta Public Service Pension Plan partial or total disability pension application.
- Completed by
- Physician
- Issued by
- Public Service Pension Plan (Alberta)
- Format
- Language
- English
LAPP LA163: Confidential Medical Statement
Alberta's Local Authorities Pension Plan needs this physician statement with every application for a partial or total disability pension. It is printed at the back of the Disability Retirement Benefits Application (LA21A), after the member and employer sections. LAPP holds it in strictest confidence and uses it solely so an independent medical consultant can assess the disability.
Who completes it
A physician completes all five sections: patient information, physician information, medical relationship, medical assessment and physician certification. The member completes and signs the application sections, and a current employer completes the employer section, which a former employer does not need to fill in.
Submitting and payment
- How to submit it
- The physician returns the completed statement to the patient, who mails or faxes it to LAPP together with the application form. LAPP asks members to submit the package before the date they want the disability pension to start, to avoid delays.
- Who pays
- Charges for completing the statement, if any, are the patient's responsibility.
Good to know
- Two yes/no questions mirror the plan tests: unable to effectively perform the regular duties of employment (partial), or a lifelong impairment that prevents any gainful occupation (total).
- The medical assessment asks for examination findings with supporting documents such as reports, x-rays or other tests, plus medications, related history and activities that worsen the condition.
- You also classify the disability as temporary (reasonable probability for recovery) or permanent (low probability for recovery), and can add any other information.
- The member's signed authorization lets physicians release information about the disabling condition to LAPP, its representatives and consulting physicians, for this application only.
Get the official form
Download the current version from the source each time; forms change without notice.
Confidential Medical Statement
Fill it with Vero
If your copy of the form is a fillable PDF, upload it 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 reviews the LAPP Confidential Medical Statement?
LAPP says the statement is used solely so an independent medical consultant can assess the patient's disability, and the decision combines that medical evidence with the plan's rules. The form also states that no information is released to unauthorized persons without the patient's prior written consent.
What is the difference between a partial and a total LAPP disability pension?
A partial disability pension may be granted when medical evidence shows the member cannot effectively perform the regular duties of their work because of a physical or mental impairment. A total disability pension needs an impairment reasonably expected to last for the rest of the member's lifetime that prevents any gainful occupation.
Who pays for the LAPP medical statement?
The patient. The statement says any charges for completing it are the patient's responsibility, and the application reminds members that they pay the cost of obtaining information about their medical condition. The physician returns the completed form to the patient, who submits it with the application.