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
Primary:
Secondary:
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Year Month Day
(please specify):
BP readings over last 6 months (including dates)
Current height Current weight Weight loss/gain to date
Date symptoms first appeared
Date of first visit
Date patient’s condition first prevented them from working:
Date of latest visit:
Date of hospital inpatient admission:
Date of discharge:
Date of hospital outpatient admission:
Name of hospital:
Subjective symptoms (including severity/frequency/duration):
•
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INITIAL ATTENDING PHYSICIAN’S STATEMENT
Cardiac 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 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 on file. Do not provide
genetic test results)
Frequency of visits:
Weekly Monthly Other
2. Findings
Chest pain of cardiac origin Syncope Fatigue Dyspnea due to vascular congestion or hypoxia
Psychophysiologic Other
Current status? Stable Improving Regressing
