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Wawanesa Life Supplementary Medical Information Form

Wawanesa Life uses this three-page statement to collect supplementary medical information on a group disability claim that is already open. It updates Wawanesa on symptoms and how they have changed, treatment and planned changes, mobility, financial competency and the earliest return-to-work date. The current version is dated May 2024.

Who completes it

The patient completes the patient authorization, which releases medical information to Wawanesa Life. The physician completes the clinical, treatment, competency, return-to-work and remarks sections.

Submitting and payment

How to submit it
Return the completed form and supporting documents to Wawanesa Life Claims by mail, fax or email.
Who pays
The patient authorization states that the patient is responsible for any fees related to completing the form.

Good to know

  • Attach a copy of the patient's chart notes, including consultation reports and test results related to the diagnosis.
  • The form asks whether the patient has recovered, improved, not improved or deteriorated, and whether they are ambulatory, use assistive devices, or are bed, hospital or home confined.
  • Describe proposed changes to the treatment plan, including a surgery date if known, investigations, medications and therapy.
  • Wawanesa requires a handwritten signature from the person responsible for completing each claim form.

Get the official form

Download the current version from the source each time; forms change without notice.

Disability Supplementary Medical Information Physician Statement

Official pagePDF

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.

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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

Does the Wawanesa supplementary form ask about competency?

Yes. It asks whether the patient can handle their own financial affairs and, if not, from what date. The return-to-work section then asks for the earliest date the patient will be able to return to work and whether they can take part in a rehabilitation program.

What can I add in the remarks section?

Any additional information that may help Wawanesa understand the patient's restrictions and limitations, functional capabilities and expected duration of impairment. By signing, the physician acknowledges the statement is kept in Wawanesa's benefits file and might be accessible to the patient or others authorized by law.