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

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

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The Attending Physicians Statement - Short Term Disability Claim/Early (Great-West Life Insurance for Personal, Group & Benefits in Canada) form is 2 pages long and contains:

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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
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:
canadalife.com • 1-855-755-6729
M5454(APS)-1/20
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
consultationreports,toCanadaLifeforthepurposeofinvestigatingandassessingmyclaim(s),administeringcoverage(s)thatImayhavewithCanada
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).
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.
TO BE COMPLETED BY THE PHYSICIAN (or Nurse Practitioner Where Applicable)
STOP
• 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
IfChildbirth Vaginal C-Section
OccupationalIllness/injury Yes No Auto Accident Yes No
Hospitalization Is/waspatienthospitalized or had day surgery
Ifsurgerywasperformedpleaseprovidedateanddescriptionofsurgery:
n n
Ifyes,date(dd/mm/yyyy): Treatment Provider:
Pleasedescribethepatient’ssymptomsincludinghistory,severityandfrequency:
n n n
Name of Specialist: Specialty: Date of Visit:
Basedonyourclinicalfindingsandobservations,pleasedescribethepatient’scurrentcognitiveand/orphysicalfunctionalabilities.
Pleaselistanycomplicationsandadditionalconditionsimpactingyourpatient’sleveloffunctionortheexpectedrecoveryperiod.
n n
Prognosis Please provide the prognosis for recovery: (if not completed on page 1)
canadalife.com • 1-855-755-6729
M5454(APS)-1/20
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
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Stamp
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Attending Physicians Statement - Short Term Disability ClaimEarly (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Completed 24 December 2020

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