Plan Member/Employee Name (Last, First, Middle Initial) Home Phone # (+ Area Code) Cell Phone # (+ Area Code)
Address (Street, City, Province, Postal Code)
Employer’s Name Group Plan Number Canada Life Employee Identication Number Date of Birth (dd/mm/yyyy)
Date Last Worked Date Returned to Work or Expected Return to Work Date
Please provide your:
Plan Member/Employee Signature Date of Consent
Secondary and/or Complications:
If Childbirth - Expected or Actual Delivery Date
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Any modification of this document without the express written consent of Canada Life is strictly prohibited.
The patient is responsible for any fees
related to the completion of this form.
Attending Physician’s Statement - Long Term Disability Claim
Plan Member/Employee Information and Consent
TO BE COMPLETED BY THE PATIENT
Please list your present medications:
Name of Medication Dosage (mg) How Often?
I authorize my healthcare or rehabilitation provider to disclose my personal information, including my medical and health information
and including consultation reports, to Canada Life Life for the purpose of investigating and assessing my claim(s), administering
coverage(s) that I may have with Canada Life Life and administering the group benefits plan. Medical and health information
excludes genetic test results.
I acknowledge that the personal information is needed by Canada Life Life for the purposes stated above. I acknowledge that my
consent enables Canada Life Life to process my claim(s) and refusing to consent may result in delay or denial of my claim(s).
This consent may be revoked by me at any time by sending a written instruction.
I confirm that a photocopy or electronic copy of this authorization shall be as valid as the original.
Attending Physician’s Statement
TO BE COMPLETED BY THE PHYSICIAN
I am the: Family Physician Consulting Specialist Other
PLEASE COMPLETE TO THE BEST OF YOUR KNOWLEDGE