•
Name (please print):
Date symptoms first appeared
Date patient’s condition first prevented them from working
Date of first visit for treatment or consultation
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INITIAL ATTENDING PHYSICIAN’S STATEMENT
Musculo-skeletal
Form
TO ALLOW US TO MAKE AN ASSESSMENT OF YOUR PATIENT’S CLAIM, PLEASE ANSWER ALL OF THE QUESTIONS IN FULL.
Instructions:
1. Please PRINT.
2. Part 1 to be completed by patient.
3. Part 2 to be completed by physician.
4. Any charge for completion of this form is the patient’s responsibility.
Part 1: Patient Authorization
Telephone Number (including area code):
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.
Part 2: Attending Physician’s Statement
1. Diagnosis (please provide copies of all relevant clinical notes, test results and consultation reports. Do not provide
genetic test results.)
Has patient ever had the same or a similar condition?
Yes No Unknown
Is condition a result of an injury due to an accident? Yes No
Is condition due to injury or sickness arising out of patient’s employment? Yes No Unknown
If yes, have Workers’ Compensation Board/CSST forms been completed? Yes No
Frequency of visits: Weekly Monthly Other
Address:
Date of birth:
Date of latest visit:
Date of hospital inpatient admission:
Date of discharge:
Date of hospital outpatient admission:
PLAN NO.
Year Month Day
Street & Number
City Province Postal Code
( )
Patient’s Signature Date
Primary:
Secondary:
Year Month Day
Year Month Day
Year Month Day
• • •
If yes, state when and describe:
• •
If yes, please describe.
Current height Current weight Weight loss / gain to date
• • •
• •
Year Month Day
• • •
Year Month Day
Year Month Day
Year Month Day
Name of hospital:
Other treating physicians:
Pending referrals to specialists:
