Plan Member/Employee Name (Last,First,MiddleInitial) Home Phone # (+ Area Code) Cell Phone # (+ Area Code)
Address (Street, City, Province, Postal Code)
Employer’sName GroupPlanNumber CanadaLifeEmployeeIdenticationNumber
Height Weight Date of Birth (dd/mm/yyyy)
Last Date Worked Date Returned to Work or Expected Return to Work Date
Plan Member/Employee Signature Date of Consent (dd/mm/yyyy)
Secondary and/or Complications:
- ExpectedorActualDeliveryDate(dd/mm/yyyy) n n
n n n n
Date of admittance (dd/mm/yyyy): Date of discharge (dd/mm/yyyy): InstitutionName:
Date (dd/mm/yyyy): Description:
Treatment (drug, dosage, physiotherapy, other):
Prognosis Please provide the prognosis for recovery:
canadalife.com • 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
Iauthorizemyhealthcareorrehabilitation 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.
PLEASE COMPLETE TO THE BEST OF YOUR KNOWLEDGE
IfChildbirth Vaginal C-Section
OccupationalIllness/injury Yes No Auto Accident Yes No
Hospitalization Is/waspatienthospitalized or had day surgery