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
Height Weight Date of Birth (dd/mm/yyyy)
Last Date Worked Date Returned to Work or Expected Return to Work Date
(dd/mm/yyyy) (dd/mm/yyyy)
Plan Member/Employee Signature Date of Consent (dd/mm/yyyy)
Primary Diagnosis:
Secondary and/or Complications:
- ExpectedorActualDeliveryDate(dd/mm/yyyy) n n
n n n n
Ifyes,dateofevent:(dd/mm/yyyy) Ifyes,dateofevent:(dd/mm/yyyy)
Dateoffirstvisittoyoupertainingtothiscondition: Firstdateofworkabsenceduetocondition:
(dd/mm/yyyy) (dd/mm/yyyy)
n n
Date of admittance (dd/mm/yyyy): Date of discharge (dd/mm/yyyy): InstitutionName:
Date (dd/mm/yyyy): Description:
Treatment (drug, dosage, physiotherapy, other):
Prognosis Please provide the prognosis for recovery: • 1-855-755-6729
The patient is responsible for any fees
related to the completion of this form.
Attending Physician’s Statement - Short Term Disability Claim/Early Referral Services
Plan Member/Employee Information and Consent: TO BE COMPLETED BY THE PATIENT
Iauthorizemyhealthcareorrehabilitation provider to disclose my personal information, including my medical and health information and including
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 for the purposes stated above. I acknowledge that my consent enables
Canada Life to process my claim(s) and refusing to consent may result in delay or denial of my claim(s).
TO BE COMPLETED BY THE PHYSICIAN (or Nurse Practitioner Where Applicable)
If your patient has returned to work or is expected to return to work within 4 weeks of the Last Date Worked, complete
Page 1 only and sign the end of the form.
For absences expected to be greater than 4 weeks, please complete Pages 1 and 2 in full.
IfChildbirth Vaginal C-Section
OccupationalIllness/injury Yes No Auto Accident Yes No
Hospitalization Is/waspatienthospitalized or had day surgery
n n
Ifyes,date(dd/mm/yyyy): Treatment Provider:
n n n
Name of Specialist: Specialty: Date of Visit:
n n
Prognosis Please provide the prognosis for recovery: (if not completed on page 1) • 1-855-755-6729
AttendingPhysician(pleaseprint) CertifiedSpecialty
Address (Street, City, Province, Postal Code)
Telephone # (+ Area Code) Fax # (+ Area Code)
Email Address
Signature Date Signed (dd/mm/yyyy)
Continuation of Attending Physician’s Statement for Absences that may be Greater than 4 Weeks
Has the patient been treated for this same or similar condition in the past? Yes No
Frequency of Visits: Weekly Monthly Other
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
If consultation report is not attached, please indicate if the patient has or will be seen by a specialist for this condition.
Isthepatientfollowingtherecommendedtreatmentprogram? Yes No
Notice to Physician
release of any information contained herein.