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PLAN NO.
Name (please print): Date of birth: Year Month Day
Address: Street & Number
City Province Postal Code
Telephone Number (including area code): ( )
Patient’s Signature Date
Year Month Day
Site of the tumor:
Type of tumor:
Histology and staging:
Year Month Day
• •
If yes, please specify diagnosis and dates of treatment.
Describe current symptoms:
Year Month Day
Current Height: Current Weight: Weight loss/gain to date:
Year Month Day
Year Month Day
Year Month Day
• • •
If other, please specify
Surgery:
Radiation:
Hormones:
Chemotherapy:
Date of cancer diagnosis:
Date symptoms first appeared:
First visit for these symptoms:
In your opinion, when did the patient’s condition first prevent him/her from working?
Date of first visit:
Date of latest visit:
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INITIAL ATTENDING PHYSICIAN’S STATEMENT
Cancer 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
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.
Part 2: Attending Physician’s Statement
1. Diagnosis (including any complications). Please attach a copy of all consultation, operative and pathology reports.
Do not provide genetic test results.
2. History
Has patient ever had the same or similar condition?
Yes No
3.
4.
5. Treatment
Frequency of visits:
Weekly Monthly Other
Treatment: Include information on all treatments to date and future treatment plan, inclusive of:
Part 1: Patient Authorization
Part 2: Attending Physician’s Statement
