Family of drug-specific prior authorization forms for Medavie group drug plans.
- Completed by
- Prescribing physician (plan member completes their part)
- Issued by
- Medavie Blue Cross
- Format
- Language
- English
NB FORM-1063E: Attending Physician's Statement (LTD)
Province of New Brunswick employees applying for long-term disability benefits, or for continuation of benefits during disability (waiver of premium), need this statement from their attending physician. Medavie Blue Cross receives the completed form, which runs three pages and includes condition-specific parts for cardiac, psychiatric and musculoskeletal claims alongside a recovery and rehabilitation plan.
Who completes it
The patient completes Part I, an authorization allowing the physician to complete and submit the form, and provides their Social Insurance Number. The attending physician completes Parts II to X, including any cardiac, psychiatric or musculoskeletal part that applies, and signs Part X.
Submitting and payment
- How to submit it
- Part X tells the physician to complete and return the form to Medavie Blue Cross by mail, fax or email, with copies of all clinic notes, test results, consultation reports and hospital discharge summaries attached.
- Who pays
- The instructions at the top of the form state that any charge for completing it is the patient's responsibility.
Good to know
- Tick whether the application is for long-term disability benefits or for continuation of benefits during disability (waiver of premium); both use FORM-1063E.
- Part II asks whether the condition arose from the patient's employment and whether WorkSafeNB forms have been completed, and lets you record a DSM, grade, class or stage scale per diagnosis.
- The cardiac part uses Canadian Cardiovascular Society functional capacity levels 1 to 4 and asks for at least three blood pressure readings from the onset of the current condition.
- The psychiatric part uses DSM-IV axes with current, highest and lowest GAF scores in the past year, and pregnancy-related claims need prenatal clinical notes attached.
Get the official form
Download the current version from the source each time; forms change without notice.
Attending Physician's Statement - Application for Benefits
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Who pays for New Brunswick's FORM-1063E?
The patient. Instruction 4 at the top of FORM-1063E states that any charge for completing the form is the patient's responsibility. The same instructions ask you to print, leave Part I to the patient and complete the remainder yourself before returning it to Medavie Blue Cross.
Which parts of FORM-1063E apply to every claim?
Parts II to IV (history, factors affecting recovery and management plan), Part IX (recovery and rehabilitation planning, marked for all conditions) and Part X (your statement and signature) apply to every claim. Parts V, VI and VII for cardiac, psychiatric and musculoskeletal conditions have N/A boxes, and Part VIII restrictions and limitations is completed if applicable.
What should be attached to the New Brunswick attending physician's statement?
The form asks for copies of all clinic notes, test results, consultation reports and hospital discharge summaries. Individual parts add admission and discharge summaries for hospital stays, operative reports for surgery, prenatal clinical notes for pregnancy, cardiac test results, and X-rays, CT or MRI reports and blood work for musculoskeletal conditions.