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Manitoba Blue Cross Attending Physician's Statement

Manitoba Blue Cross requires an employee's statement, an employer's statement and an attending physician's statement for a disability benefits application, and this form is the physician's part. It is the industry Initial Disability Insurance Medical Statement in Manitoba Blue Cross branding, with disability benefits underwritten by Blue Cross Life Insurance Company of Canada.

Who completes it

The doctor, or applicable medical provider, completes Section 2 (Medical Statement), identifying themselves as family physician, consulting specialist or other. The patient completes and signs Section 1, including medications, height, weight, dominant hand and consent to release medical information.

Submitting and payment

How to submit it
The form says to submit it directly to Manitoba Blue Cross Case Management Services by email, fax or mail.
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 the disability will last less than 4 weeks, stop after the hospitalization and surgery questions and sign the end of the form.
  • Attach relevant test results, consultation reports and clinical notes; unattached test results are interpreted as tests not performed, and genetic test results should not be sent.
  • Manitoba Blue Cross lists the form under disability benefit forms as the attending physician's statement and notes it is also available in French on request.
  • Section 2 asks whether the condition stems from an occupational illness or injury, a motor vehicle accident or another accident, and whether you recently completed other disability forms, such as CPP, QPP or WCB.

Get the official form

Download the current version from the source each time; forms change without notice.

Initial Disability Insurance Medical Statement

Official pagePDF

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.

See how Vero Documents works

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

Is the Manitoba Blue Cross attending physician's statement available in French?

The form posted on the Manitoba Blue Cross download page is in English, and the page notes that it is also available in French on request. The English version is the CLHIA Initial Disability Insurance Medical Statement, version June 2025, with Manitoba Blue Cross branding.

What does Section 2 of the Manitoba Blue Cross medical statement cover?

Section 2 covers primary and secondary diagnoses, the cause of the condition, first visit and first absence dates, treatment and response, hospitalization and surgery, then investigations, clinical findings, cognitive and physical restrictions and limitations, licence restrictions, ability to manage own affairs, contributing factors, prognosis and return-to-work goals.

Who pays to complete the Manitoba Blue Cross disability medical statement?

The patient. A box on page 1 and the consent in Section 1 state that the patient is responsible for any fees related to completing the form. The completed statement is submitted directly to Manitoba Blue Cross Case Management Services by email, fax or mail.