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
Medavie Blue Cross FORM-149E: Critical Condition APS
Medavie Blue Cross uses this two-part statement for the physician's evidence in a group critical condition (critical illness) benefit claim. After the patient's authorization, the physician documents diagnoses, symptom and treatment dates, hospital and surgical care, objective and subjective findings, effects on daily living, cardiac functional capacity where relevant, and a prognosis referenced to the list of critical conditions.
Who completes it
The attending physician completes Part 2 (Attending Physician's Statement) and signs it. The patient completes Part 1, authorizing release of information to the insurer and the policyholder.
Submitting and payment
- How to submit it
- The form prints Medavie Blue Cross mail, fax and email return details, and the claim also uses the Critical Condition Claim Form (FORM-182) and the employer's statement (FORM-1143).
Good to know
- For a cancer diagnosis, include a copy of the pathology report; for cardiac claims, forward stress test and angiogram results with the functional class.
- Cardiac functional capacity is graded on the Canadian Cardiovascular Society scale from Class 1 (no limitations) to Class 4 (complete limitations).
- Describe how the condition affects eating, dressing, bathing, ambulation and toileting, and whether the patient is competent to endorse cheques and direct the use of proceeds.
- The form asks whether the patient has had the same or a similar condition before, with dates and details, and which other physicians treated the present condition.
Get the official form
Download the current version from the source each time; forms change without notice.
Attending Physician’s Statement – Critical Condition Benefit
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
What attachments go with Medavie's critical condition attending physician's statement?
For cancer diagnoses, a copy of the pathology report. The form also asks you to attach copies of tests administered, with the results of relevant clinical findings, when summarizing the medical history, and to forward stress test, angiogram and similar results when rating cardiac functional capacity.
Which forms make up a Medavie Blue Cross critical condition claim?
The physician's FORM-149E is used with the Critical Condition Claim Form (FORM-182) and the Life, AD&D and Critical Illness Form employer's statement (FORM-1143). The first part of the physician statement is the patient's authorization to release information to the insurer and the policyholder.
How should the prognosis be written on FORM-149E?
The form asks you to outline your prognosis with reference to the list of critical conditions, after listing all objective and subjective findings and describing how activities of daily living are affected. A remarks field follows for anything else relevant to the claim before you print your name and sign.