Medavie Blue Cross lists this form as the Disability Benefits Attending Physician's Statement for its group disability plans. It is Medavie's copy of the industry Initial Disability Insurance Medical Statement, printed as FORM-401E with an October 2025 version date, plus a fifth page listing where to send it. It travels with the employee's (FORM-400E) and employer's (FORM-399E) statements.
The patient completes Section 1, including medications, height, weight and a signed consent. The family physician, consulting specialist or other medical provider completes Section 2, the Medical Statement, and checks which of those roles applies.
Download the current version from the source each time; forms change without notice.
Initial Disability Insurance Medical Statement
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.
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The fifth page of FORM-401E tells you to email, fax or mail the completed statement to the provincial Medavie Blue Cross office that corresponds to the patient's province. It lists offices for New Brunswick and Atlantic Canada, Quebec, Ontario and Nova Scotia, and asks you to choose the office for your patient's province.
It carries the same title and sections as the industry Initial Disability Insurance Medical Statement, with Medavie's form number, an October 2025 version date and an extra page of Medavie office contacts. The patient section, medical statement and the notice about who may access the information are unchanged.