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-STD: Mental Health STD APS
Co-operators Life uses this four-page statement for group short-term disability claims when the primary diagnosis is a mental health condition. It covers diagnosis, DSM-5 symptoms and screening results, treatment and response, functional impact, complicating factors and the return-to-work outlook. The current version is GL2554-STD, dated 09/24.
Who completes it
The plan member completes the information and authorization section. The treating physician completes the Medical Information pages, notes whether they are the family physician, and signs.
Submitting and payment
- How to submit it
- Send it to Co-operators' Disability Claims Department using the mail, fax or email contacts at the top of the first page.
- Who pays
- As stated on the form, the cost of completing it is the plan member's responsibility.
Good to know
- The form's important note says to use a mental health statement only when the primary diagnosis is a mental health condition; other conditions have a separate statement.
- Record visit frequency (weekly, bi-weekly or monthly), the next visit date, and whether symptoms have improved, not changed or worsened.
- The form asks whether any licence held by the patient has been restricted or revoked because of the condition, and as of when.
- After checking the complicating factors, describe the supports in place or planned to help with those issues.
Get the official form
Download the current version from the source each time; forms change without notice.
Short Term Disability – 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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Who decides whether the employee is disabled?
A Co-operators Disability Case Manager. According to Co-operators' employer guide, the case manager reviews the job description and duties, medical information from physicians and other providers, and information from the employee and employer, then decides whether the policy's definition of total disability is met.
What should be attached to the Co-operators STD mental health statement?
Copies of chart notes, test results and consultation reports. The form also asks for screening results, such as MMPI-2, PHQ-9 or GAD-7, and for each medication's initial and current dosage with dates and the patient's response.
Can the physician give an email address to Co-operators?
Yes. The physician section has an optional email address for Co-operators to communicate about the claim, with an acknowledgement that internet transmissions may be intercepted. The plan member section has the same option for the member's own email.