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-969E: Terminal Illness Claim
Medavie Blue Cross uses this two-page form when an insured employee claims a terminal illness benefit, which pays a portion of group life insurance proceeds to the insured. The claimant statement sets out the amount requested and banking details, and the attending physician's statement on page 2 gives the diagnoses, the date symptoms appeared and a mandatory opinion on life expectancy.
Who completes it
The attending physician completes Part 2 of the page 2 statement and signs it, and the patient signs the Part 1 authorization. The employee completes the claimant statement, an irrevocable beneficiary signs the release if applicable, and the group administrator completes the employer statement (FORM-1143).
Submitting and payment
- How to submit it
- The form prints Medavie Blue Cross mail, fax and email return details for its regional offices, and the group administrator submits the employer statement to Medavie Blue Cross.
Good to know
- The life expectancy question is marked mandatory; give your opinion of the patient's life expectancy alongside primary and secondary diagnoses and additional conditions or complications.
- If a beneficiary is irrevocable, that beneficiary must sign a release of their rights to the portion of proceeds payable under the terminal illness provision.
- If the claimant is under 18, the policyholder, parent or legal guardian signs the claimant authorization, which also needs a witness signature.
- The claimant attaches a void cheque or direct deposit information from online banking to the claim.
Get the official form
Download the current version from the source each time; forms change without notice.
Terminal Illness Claim Form
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
Is the life expectancy question mandatory on Medavie's terminal illness form?
Yes. Part 2 of the attending physician's statement asks, in bold, for your opinion of the patient's life expectancy and marks the question mandatory. It also asks for primary and secondary diagnoses, additional conditions or complications, the date symptoms appeared and any other information relevant to the application.
What else is needed for a Medavie terminal illness claim?
The employee completes the claimant statement with the amount requested and attaches a void cheque or direct deposit information. An irrevocable beneficiary must sign a release, and the group administrator completes the Employer Statement (FORM-1143) and submits it to Medavie Blue Cross.
Who signs the patient authorization on FORM-969E?
The patient signs Part 1 of the attending physician's statement, authorizing release to the insurer of any information about the application. On the claimant authorization, a witness also signs, and if the claimant is under 18, the policyholder, parent or legal guardian must sign.