Fillable form field.: Attending Physicians Statement (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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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 Date of Birth (dd/mm/yyyy)
Date Last Worked Date Returned to Work or Expected Return to Please provide your:
(dd/mm/yyyy) Work Date, if known (dd/mm/yyyy) Height: Weight:
Plan Member/Employee Signature Date of Consent (dd/mm/yyyy)
• • •
Primary:
Secondary:
• •
If so, date of event: (dd/mm/yyyy)
Details:
Date of first visit to you pertaining to this condition First date of work absence due to this condition:
(dd/mm/yyyy) (dd/mm/yyyy)
• •
If yes, date: (dd/mm/yyyy) By whom:
• •
If yes, please indicate requestor: (other insurance company, CPP, QPP, Workers Compensation Board, etc.)
This document contains both information and form fields. To read information, use the Down Arrow from a
form field.
canadalife.com 1-855-755-6729
M4307B(MHC)-1/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
Any modification of this document without the express written consent of Canada Life is strictly prohibited.
Attending Physician’s Statement
Mental Health
Conditions
Section A
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 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 understand that I am responsible for any fees related to the completion of this form.
I confirm that a photocopy or electronic copy of this authorization shall be as valid as the original.
Section B
Attending Physician’s Questionnaire
TO BE COMPLETED BY THE DOCTOR
I am the: Attending Physician Consulting Specialist Other (please specify)
PLEASE COMPLETE TO THE BEST OF YOUR KNOWLEDGE
1. Diagnosis
Is this condition related to: Occupational Illness/injury Auto accident
Has the patient been treated for this same or similar condition in the past? Yes No
Have you completed any other disability claim forms recently for this patient? Yes No
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Please describe the patient’s current symptoms including frequency and severity:
• • • •
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Observations or comments supporting the above:
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Please describe:
Please describe the supports in place, or planned, to assist with these issues:
M4307B(MHC)-1/20
canadalife.com • 1-855-755-6729
2. Patient’s Description of Symptoms
3. Your Clinical Findings and Observations
Please describe how the condition has impacted the following and to what degree:
No impact Mild Moderate Severe
Appearance
Memory
Energy / Vigour
Behaviour
Decision Making
Socialization
Concentration / Focus
Speech
Affect / Mood
Insight / Judgment
Self-Criticism
4. Complicating Factors
Please indicate all factors that may have contributed to the clinical problem(s) and may complicate the patient’s recovery period:
Workplace Issues
Social / Family Issues Financial / Legal Problems
Physical Condition Alcohol / Drug Abuse Medication Side Effects
Pain Perception Coping Skills Personality / Motivation Other
• • Date report expected: (dd/mm/yyyy)
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1.
2.
Reason for requesting the consultation:
• • •
If yes, as of when? (dd/mm/yyyy) Type of licence:
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1.
2.
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M4307B(MHC)-1/20
canadalife.com • 1-855-755-6729
5. Investigations
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
Are tests / investigations / consultations pending? Yes No
Does the patient have an appointment booked with an specialist(s) in the near future? Yes No
Name of Specialist Specialty Date of Appointment:
(dd/mm/yyyy)
Has any license held by the patient been restricted or revoked as a result of this condition? Yes
No Don’t know
6. Medications (please attach separate list if insufficient space)
Medication Name Initial dosage and
date started
(dd/mm/yyyy)
Current dosage and date
changed if applicable
(dd/mm/yyyy)
Response
7. Hospitalization
Is/was the patient hospitalized? Yes No Is future hospitalization anticipated? Yes No
Date admitted
(dd/mm/yyyy) Date discharged (dd/mm/yyyy) Institution Name
8. Treatment Details - Psychological (e.g.: cognitive behavioural, drug/alcohol, group, family, marital, Day Hospital program)
Type of therapy Name of provider
or facility
Date
treatment
began
(dd/mm/yyyy)
Frequency of
visits
Date of
last visit
(dd/mm/yyyy)
Response
Wkly
Mthly
Other
Wkly
Mthly
Other
Wkly
Mthly
Other
Wkly
Mthly
Other
• • • •
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Please explain:
• •
If so, please explain:
What return-to-work goals have been discussed with the patient? Please explain:
Please provide the patient’s prognosis for improvement:
Please provide any other information that will help us understand the patient’s current condition recovery goals and prognosis:
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Attending Physician (please print) Certified Specialty Physician’s Stamp
Address (Street, City, Province, Postal Code)
Telephone # (+ Area Code) Fax # (+ Area Code)
Email Address
Signature Date Signed (dd/mm/yyyy)
M4307B(MHC)-1/20
canadalife.com • 1-855-755-6729
9. Treatment Details - Concurrent Physiological Disorders, if known (e.g.: physiotherapy, chiropractic, other rehabilitation therapy)
Type of therapy Name of provider
or facility
Date
treatment
began
(dd/mm/yyyy)
Frequency of
visits
Date of
last visit
(dd/mm/yyyy)
Response
Wkly
Mthly
Other
Wkly
Mthly
Other
Wkly
Mthly
Other
Wkly
Mthly
Other
10. Overall Response to Treatment
Please describe the response to treatment to date:
Complete Partial None Too soon to tell
Is the patient following the recommended treatment program? Yes No
Are there any plans to change or augment the current treatment program? Yes No
11. Prognosis and Recovery
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.
Clear
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Completed 24 December 2020

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