Fillable ATTENDING PHYSICIANS STATEMENT GENERAL (Equitable Life of Canada)

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ATTENDING PHYSICIANS STATEMENT GENERAL (Equitable Life of Canada)

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Country of origin: CANADA
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Head Office
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
TF 1.80 0.265.4556 T 519.886.5210
www.equitable.ca
ATTENDING PHYSICIAN’S STATEMENT GENERAL
To allow us to make an assessment of your patient’s file, please answer all of the questions in full. Incomplete responses or
missing information will cause delays in the assessment and handling of this file. Any charge for completing this form is the
patient’s responsibility.
Instructions:
Please PRINT.
Part 1 to be completed by patient.
Part 2 to be completed by physician.
Par t 1: PATIENT AUTHORIZATION
Policy Number: Certificate Number:
Name Date of Birth
DD / MM / YYYY
Address
(number, street, city, province and postal code)
Phone Number (include area code)
I hereby authorize the release to Equitable Life of Canada
®
any information requested by Equitable Life of Canada in respect of this file.
Patient’s Signature
Part 2: ATTENDING PHYSICIAN’S STATEMENT Please note: Any charge for completing this form is the patient’s responsibility
1(a). Diagnosis
Date
DD / MM / YYYY
Patient’s Last Name Patient’s First Name Date of Birth
DD / MM / YYYY
Primary:
Secondary:
Subjective symptoms (including severity, frequency, duration):
Please enclose copies of current imaging reports, EKGs, Laboratory Data.
(b). Mental/Nervous Impairment (if applicable)
History:
Are work related issues contributing to your patient’s condition?
Changes in Activities of Daily Living habits
Familial risk factors
£ Yes £ No. If yes, provide date and results.
Description of patient’s presentation
Progress with treatment plan
Did you complete a mental status examination.
Are pati
ent’s symptoms related to drug or alcohol or other substance abuse?
£ Yes £ No
£ Yes £ No
If yes, state facility:
£ Yes £ No If yes, state when
If yes, is patient enrolled in a substance abuse program?
Has your p
atient ever been enrolled in a substance abuse program?
The Equitable Life Insurance Company of Canada 188QA(2020/06/30) Page 1 of 4
ATTENDING PHYSICIAN’S STATEMENT GENERAL
Part 2: ATTENDING PHYSICIAN’S STATEMENT CONTINUED Please note: Any charge for completing this form is the patient’s responsibility
2. History
If patient is pregn
ant, give EDC
Date symptoms first appeared or accident happened:
DD / MM / YYYY
Date patient stopped working due to this condition:
DD / MM / YYYY
£ Yes £ No £ Unknown
If yes, please specify diagnosis and dates of treatment:
£ Yes £ No £ Unknown
Has patient ever had a same or similar condition?
Is condition due to injury or sickness arising out of patient’s employment?
Current height
Current weight Weight loss/gain in past 6 months
3. T
reatment Dates
£ ft/in £ cm £ lbs £ kg £ lbs £ kg
Date of first visit for current condition:
DD / MM / YYYY
Date of most recent visit:
DD / MM / YYYY
£ Weekly £ Monthly £ Other (specify)
Date of hospital in-patient admission:
DD / MM / YYYY
Date of discharge:
DD / MM / YYYY
Date of hospital out-patient admission:
DD / MM / YYYY
Name of hospital:
DD / MM / YYYY
Medications (dose, frequency, date prescribed)
Surgeries (including dates)
Other (including frequency)
£ Yes £ No (please elaborate)
Frequency of visits:
4. Nature of Treatment
I
s patient following recommended treatment program?
5. Progress
H
as patient:
£ Recovered £ Improved £ Not Improved £ Retrogressed since the patient stopped working
If the patient’s condition has not improved/recovered, why not?
The Equitable Life Insurance Company of Canada 188QA(2020/06/30) Page 2 of 4
ATTENDING PHYSICIAN’S STATEMENT GENERAL
Part 2: ATTENDING PHYSICIAN’S STATEMENT CONTINUED Please note: Any charge for completing this form is the patient’s responsibility
6. Indicate your patients functional capacity below for each question by checking “R” for Restriction (what your patient
should not do) or “L” for Limitation (what your patient is unable to do).
Lifting Under 11lbs (4.98 kg) 11-22 lbs (4.98-9.97 kg) 22-24 (9.97- 10.88 kg) Over 44 (19.95 kg)
Carrying Under 11lbs (4.98 kg) 11-22 lbs (4.98-9.97 kg) 22-24 (9.97- 10.88 kg) Over 44 (19.95 kg)
Reaching Above shoulder height At shoulder height Below shoulder height
R £ L £ R £ L £ R £ L £ R £ L £
R £ L £ R £ L £ R £ L £ R £ L £
R £ L £ R £ L £ R £ L £
Sitting hours Overhead Lifting hours
Standing hours Pushing/Pulling hours
Walking hours Gripping hours
Pinching hours Keyboarding hours
7. Competency
Do you believe your patient is competent to cash cheques and use the proceeds?
Have you referred the case to the Public Trustee?
Have any referr
als been made to specialists or other treatment providers?
8. Return to work plans
£ Yes £ No
If no, why not?
£ Yes £ No
£ Yes £ No
If yes, please provide name and address of doctor referred to and appointment date.
Have you discussed return to work with your patient?
Prognosis for recovery:
List barriers to begin a return to work plan.
Can your patient participate in a gradual or modified return to work plan?
Please describe any other factors impacting your patients recovery and return to work.
The Equitable Life Insurance Company of Canada 188QA(2020/06/30) Page 3 of 4
ATTENDING PHYSICIAN’S STATEMENT GENERAL
Part 2: ATTENDING PHYSICIAN’S STATEMENT CONTINUED Please note: Any charge for completing this form is the patient’s responsibility
9. Rehabilitation
Is your patient a suitable candidate for medical rehabilitation services?
(i.e. cardiopulmonary program, speech therapy, physiotherapy,CBT etc.)
Is patient a suitable candidate for vocational rehabilitation?
10. Comments
11
. Have you completed other requests regarding your patient’s current medical condition to other sources, i.e. other insurance
providers, Canada Pension Plan, provincial workers compensation plan, etc.?
The information in this statement will be kept in a life, health, or disability benefits file with the insurer or plan
administrator and might be accessible by the patient or third parties to whom access has been granted or those
authorized by law. By providing the information I consent to such unedited release of any information contained herein.
Physician’s signature
£
Yes £ No If yes, please specify. If no, why not?
£ Yes £ No
If yes, please specify:
Is there any other information you wish to add that will give us a better understanding of your patient’s condition or treatment requirements?
£ Yes £ No
If so, please provide details:
Name of Physician (please print)
Specialty:
Telephone: Fax:
Address (number, street, city, province & postal code):
Date:
DD / MM / YYYY
Fax this completed form, along with any other pertinent documentation to 1.888.505.4373
or mail to (do not use staples):
Equitable Life of Canada
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn Waterloo, Waterloo Ontario N2J 4C7
Please keep a copy of this form for your records.
Please note: Equitable Life cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is
intercepted and misused. If you would prefer to submit your information by another means, please contact us at 1.80 0.265.4556.
The Equitable Life Insurance Company of Canada 188QA(2020/06/30) Page 4 of 4
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Completed 1 March 2021

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