Physician statement accompanying a LAPP partial or total disability pension application.
- Completed by
- Physician
- Issued by
- Local Authorities Pension Plan (LAPP)
- Format
- Language
- English
Alberta PSPP PS163: Confidential Medical Statement
Members of Alberta's Public Service Pension Plan who apply for a partial or total disability pension send this physician statement with the Disability Retirement Benefits Application (PS21A). The plan keeps it in strictest confidence and uses it solely for an assessment of the disability by an independent medical consultant. The pension decision combines that medical evidence with the plan's rules.
Who completes it
A physician completes the whole statement, sections 1 to 5, from patient and physician information through the medical assessment and certification. The member completes the application sections, and a current employer completes sections 7 and 8; a former employer does not have to.
Submitting and payment
- How to submit it
- The physician returns the completed statement to the patient, who mails or faxes it to PSPP with the application. PSPP recommends submitting before the date the member wants the pension to begin.
- Who pays
- Any charge for completing the statement is the patient's responsibility.
Good to know
- Two yes/no questions ask whether the patient is incapable of effectively performing the regular duties of employment, and whether the impairment will last for life and prevent any gainful occupation.
- Attach supporting documentation such as reports, X-rays or other tests, and list medications, relevant history, other medical problems and activities that worsen the condition.
- Members with combined pensionable service must also complete an application for the related plan to start that plan's disability pension.
- The current printing is PS163_12/2020; its questions match the LA163 statement used by Alberta's Local Authorities Pension Plan.
Get the official form
Download the current version from the source each time; forms change without notice.
Confidential Medical Statement
Fill it with Vero
If your copy of the form is a fillable PDF, upload it 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 is eligible for a PSPP disability pension?
The application says members must have commenced contributions to PSPP, or have combined pensionable service and have commenced contributions to the Management Employees Pension Plan on or before June 30, 2007. Medical evidence must then show a partial or total disability as the plan defines it.
What does the physician send back with the PSPP statement?
The form asks for examination findings and supporting documentation such as reports, X-rays or other tests. It also asks whether the disability is temporary, with a reasonable probability of recovery, or permanent, with a low probability of recovery, and leaves space for additional information.
Does the employer see the Confidential Medical Statement?
The statement is held in strictest confidence for the independent medical consultant, and no information is released to unauthorized persons without the patient's prior written consent. The employer completes its own section, which covers job duties, Workers' Compensation and long-term disability benefits.