Family of condition-specific physician statements for group critical illness claims, including dependent children's covered illnesses.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Language
- English
Co-operators GL2554-EI: Early Intervention APS (Mental)
Co-operators Life uses this four-page statement in its group early intervention program when the plan member's primary diagnosis is a mental health condition. It asks for DSM-5 symptoms, screening results, treatment response and functional impact so Co-operators can review the member's rehabilitation potential. Co-operators says it encourages rehabilitation, job accommodation and modified or part-time duties to bring employees back as soon as medically possible.
Who completes it
The plan member completes their details, including the plan sponsor or employer name, and signs the authorization. The treating physician completes the Medical Information pages and signs the physician acknowledgement.
Submitting and payment
- How to submit it
- Return it to Co-operators Life Insurance Company's Disability Claims Department by mail, fax or email, using the contacts printed on the form.
- Who pays
- The form states that the plan member is responsible for the cost of completing it.
Good to know
- Co-operators has two statements, one for mental health conditions and one for all other conditions; choose by primary diagnosis, since the wrong form can delay the claim.
- List symptoms supporting the DSM-5 diagnosis with frequency and severity, and any screening results such as MMPI-2, PHQ-9 or GAD-7.
- Rate the impact on 16 areas, from self-care, concentration and memory to sleep, appetite, housekeeping and caregiver activities, as none, mild, moderate or severe.
- Complicating factors include alcohol or drug use, workplace, family or financial issues, medication side effects, pain perception, self-harm behaviour, coping skills and motivation.
Get the official form
Download the current version from the source each time; forms change without notice.
Early Intervention – Attending Physician’s Statement for Mental Health Conditions
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
Which Co-operators early intervention form should I use?
Base it on the patient's primary diagnosis. GL2554-EI is the attending physician's statement for mental health conditions; Co-operators has a separate statement for all other conditions and warns that submitting the incorrect form could delay the claim. The employer completes its own Early Intervention plan sponsor statement.
What treatment details does GL2554-EI ask for?
Hospitalizations, each medication with initial and current dosage, dates and response, each therapy with provider, specialty, frequency and response, and any specialist care. It also asks about concurrent physical illness or injury and its treatment, and whether the diagnosis has been communicated to the patient.
Can the physician complete the Co-operators statement online?
Co-operators' employer guide says that when an employee submits a disability claim online, they can request the attending physician statement electronically, and the physician completes and submits it online. Otherwise, the paper form goes back to the Disability Claims Department by mail, fax or email.