Fillable Attending Physicians Statement - Long Term Disability Claim (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Attending Physicians Statement - Long Term Disability Claim (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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The Attending Physicians Statement - Long Term Disability Claim (Great-West Life Insurance for Personal, Group & Benefits in Canada) form is 4 pages long and contains:

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  • 123 other fields

Country of origin: CANADA
File type: PDF

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•
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 Identication Number Date of Birth (dd/mm/yyyy)
Date Last Worked Date Returned to Work or Expected Return to Work Date
(dd/mm/yyyy) (dd/mm/yyyy)
Please provide your:
1.
2.
3.
4.
5.
• •
Plan Member/Employee Signature Date of Consent
(dd/mm/yyyy)
• • •
Primary:
Secondary and/or Complications:
If Childbirth - Expected or Actual Delivery Date
(dd/mm/yyyy)
This document contains both information and form fields. To read information, use the Down Arrow
from a form field.
canadalife.com 1-855-755-6729
M4307B(OC)-1/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
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
Other Conditions
Section 1
Plan Member/Employee Information and Consent
TO BE COMPLETED BY THE PATIENT
Please list your present medications:
Name of Medication Dosage (mg) How Often?
Dominant Hand:
Left
Right
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.
Section 2
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
1. Diagnosis
(please specify)
Height:
Weight:
• • • •
If yes, date of event: (dd/mm/yyyy) If yes, date of event: (dd/mm/yyyy)
• •
If yes, please indicate requestor: (other insurance company, CPP, QPP, Workers Compensation Board, etc.)
Date of first visit to you pertaining to this condition: First date of work absence due to condition:
(dd/mm/yyyy) (dd/mm/yyyy)
e.g. Special Programs, Therapies, Medications: (if not noted by patient in Section 1)
• • •
Date of last visit: (dd/mm/yyyy)
• •
If yes, date: (dd/mm/yyyy) Treatment provider:
• •
Please elaborate:
• • • •
• •
If so, please explain:
• • • •
1.
2.
3.
1.
2.
M4307B(OC)-1/20
canadalife.com • 1-855-755-6729
Is this condition due to:
Occupational Illness/injury
Yes No Auto Accident Yes No
Have you completed any other disability claim forms recently for this patient? Yes No
Treatment
Frequency of Visits: Weekly
Monthly Other
Has the patient been treated for this same or similar condition in the past? Y
es No
Is the patient following the recommended treatment program? Yes No
Response to Treatment
Please describe the response to treatment to date: Complete
Partial None Too soon to tell
Are there any plans to change or augment the current treatment program? Yes No
Hospitalization
Is/was the patient hospitalized? Yes No Is future hospitalization planned? Yes No
Date of admittance
(dd/mm/yyyy) Date of discharge (dd/mm/yyyy) Institution Name
If surgery was/will be performed, please provide date(s) and description of surgery(s):
Date
(dd/mm/yyyy) Description
(describe)
• •
•
1.
2.
•
1.
2.
Please describe the patient’s symptoms including history, severity and frequency:
• • •
→
Based on your clinical ndings and observations, please describe the patient’s current cognitive and/or physical functional abilities:
M4307B(OC)-1/20
canadalife.com • 1-855-755-6729
Investigations
Please attach copies of all relevant:
• test results/investigations (if test results are not attached, we will interpret this as tests were not performed)
• consultation reports
• do not provide genetic test results
Are tests/investigations pending? Yes
No
Date
(dd/mm/yyyy) Description
If consultation report is not attached, will the patient be seen by a specialist(s) for this condition in the future?
Yes
No
Name of Specialist Specialty Date (dd/mm/yyyy)
Clinical Findings and Observations
How have the patient’s symptoms evolved to date? Improved
No Change Retrogressed
Functional Abilities
Attending Physician (please print) Certified Specialty Physician’s Stamp
Address (Street, City, Province, Postal Code)
Telephone # (+ Area Code) Fax # (+ Area Code)
Email Address
Signature Date Signed (dd/mm/yyyy)
• •
If yes, as of when? (dd/mm/yyyy) Type of licence:
• • Please elaborate:
Please provide the patient’s prognosis for improvement and/or recovery:
What return-to-work goals have been discussed with the patient? Please elaborate:
M4307B(OC)-1/20
canadalife.com • 1-855-755-6729
Has any licence held by the patient been restricted or revoked as a result of this condition? Yes No
Are there other non-medical factors that may impact the patient’s expected recovery period and return-to-work goals?
Yes No
Prognosis
Return-to-Work
Notice to Physician
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.
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Attending Physicians Statement - Long Term Disability Claim (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Completed 24 December 2020

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