Form 1048 Aps O PDF Details

Navigating the process of applying for disability benefits can be a daunting task, requiring a thorough understanding of the required documentation. Among these essential documents is the 1048 Aps O form, an integral component designed to gather comprehensive information to support a disability claim. This form is meticulously structured to ensure a detailed assessment of the claimant's condition, divided into distinct parts for completion by both the patient and their attending physician. Patients are responsible for the first section, where they must provide personal identification details, consent for the release of medical information, and authorize the use of their Social Insurance Number. The lion's share of the form, however, is dedicated to the attending physician’s questionnaire, which dives deep into the diagnosis, symptoms, physical findings, and the treatment administered to the patient, along with information on any laboratory tests conducted. Furthermore, there are explicit instructions indicating that any costs incurred for completing this form fall on the patient, reinforcing the form's role in enabling a comprehensive evaluation of the disability claim by gathering critical data from medical professionals and the claimants themselves.

QuestionAnswer
Form NameForm 1048 Aps O
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namess5_010459 attending physician disability questionnaire form

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Ins tructions

1 . Pleas e PR INT.

2 . Part 1 to be completed by patient.

3 . Part 2 to be completed by phys ician.

4. Any charge for completing this form is the patient’s responsibility.

Attending Physician’s Statement For Disability Benefits

TO ALLOW US TO MAKE AN ASSESSMENT OF YOUR PATIENT’S CLAIM

IT IS IMPERATIVE THAT YOU ANSWER ALL OF THE QUESTIONS IN FULL.

Policy and Certificate No.

Part 1: Patient Authorization

Name

Date of Birth (day, month, yea r)

Addres s (number, s treet, city, province, pos tal code)

I certify that the above statements are true and I hereby authorize The Canada Life Assurance Company and its authorized agents, including its legal representatives and investigators to obtain, receive, examine, copy and disclose any records or knowledge of me or my health, INCLUDING CONSULTATION REPORTS, from, or give to, any employer, physician, medical practitioner, hospital, clinic, attorney, investigative agency, insurance company and insurance support organization.

The purpose for which this information is collected is: i) to adjudicate my claim, ii) for the employer’s and policyholder’s statistical purposes, and iii) for whatever purposes the employer, policyholder and insurer so require.

A photographic copy of this authorization shall be as valid as the original. I hereby authorize the use of my Social Insurance Number for the administration of the benefits under this group policy.

Patient’s Signature

Date (day, month, year)

Part 2: Attending Physician’s Questionnaire

1.DIAGNOSIS OF PRESENT CONDITION

Primary __________________________________________________________________________________________________________________________

Secondary _______________________________________________________________________________________________________________________

Has patient had same or similar condition in the past?

 

 

 

Yes No

If “Yes”, provide date(s) (day, month, yea r)

____ /____ /____

____ /____ /____

____ /____ /____

Date first seen ____ /____ /____ Date last seen____ /____ /____ Frequency of visits: Weekly

Monthly Other _____________________

Other treating physicians ___________________________________________________________________________________________________________

2.SYMPTOMS

Pain in the (cervical, thoracic, lumbosacral) area

Stiffness or impaired range of motion

 

(circle one or more)

 

 

Subjective weakness or incoordination

Parasthesias or sensory disturbance in radicular or dermatomal pattern in the

 

 

 

(arms(s), leg(s), trunk) (circle one or more)

Other (please specify) __________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

3.PHYSICAL FINDINGS

Distinct muscle spasm

Loss or distortion of normal spine curves

Neurological deficits: Power

Yes

No

If yes, explain _____________________________________________________________

Sensory Loss

Yes

No

If yes, explain _____________________________________________________________

Reflexes

Yes

No

If yes, explain _____________________________________________________________

Specific reliable and reproducible signs (please list) ________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Limitation of movement:

 

 

 

Forward flexion ________ degrees

Rotation ________ degrees

Lateral flexion ________ degrees

SLR ________ degrees

Limitations preventing return to work _______________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

4.TREATMENT

Medication: (dose/frequency/date) __________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Physiotherapy (type/frequency/date) _________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Please specify if done in clinic, hospital or home ______________________________________________________________________________________

Surgery Date (past): Day _____ Month _____ Year_____ Type: ________________________________________________________________________

Surgery Date (future): Day _____ Month _____ Year _____ Type: _______________________________________________________________________

1048 APS-O 11/05

5. RESULTS OF LABORATORY TESTS

Dates

X-rays

____________________________________________________________________________________

____ /____ /____

____ /____ /____

Cat Scan/MRI ____________________________________________________________________________

____ /____ /____

____ /____ /____

EMG Studies ______________________________________________________________________________

____ /____ /____

____ /____ /____

Other

____________________________________________________________________________________

____ /____ /____

____ /____ /____

Is patient compliant with prescribed measures? Yes No

 

 

PLEASE ATTACH COPIES OF RELEVANT TEST RESULTS

6.RESTRICTIONS AND LIMITATIONS

 

 

 

Total hours

 

 

 

 

Functional capacity:

SITTING

8

7

6

5

4

3

2

1

_____________________________________________________________Other

 

STANDING

8

7

6

5

4

3

2

1

_____________________________________________________________Other

 

WALKING

8

7

6

5

4

3

2

1

_____________________________________________________________Other

What specific factors, if any, interfere with the patient’s ability to sit, stand or walk? _______________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

What devices might improve the patient’s ability to sit, stand or walk? ___________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

 

Patient is able to:

Yes/no

 

Frequency

 

Duration

 

 

 

 

 

 

 

 

 

 

 

Drive

 

 

 

 

 

 

 

 

 

 

 

 

 

Crouch

 

 

 

 

 

 

 

 

 

 

 

 

 

Balance

 

 

 

 

 

 

 

 

 

 

 

 

 

Bend

 

 

 

 

 

 

 

 

 

 

 

 

 

Twist

 

 

 

 

 

 

 

 

 

 

 

 

 

Stoop

 

 

 

 

 

 

 

 

 

 

 

 

 

Kneel

 

 

 

 

 

 

 

 

 

 

 

 

 

Squat

 

 

 

 

 

 

 

 

 

 

 

 

 

Climb Stairs

 

 

 

 

 

 

 

 

 

 

 

 

 

Reach at shoulder level

 

 

 

 

 

 

 

 

 

 

 

 

 

Reach above shoulder level

 

 

 

 

 

 

 

 

 

 

 

 

 

Reach below shoulder level

 

 

 

 

 

 

 

 

 

 

 

 

7.PROGNOSIS

When do you anticipate the patient can return to work? ____ /____ /____

Own occupation: ____ /____ /____

Any occupation: ____ /____ /____

Or, if unable to determine, follow-up in _______ months

Is there any restriction you would like to see placed on patient’s return to work?

Yes No Please comment ________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Assessment and treatment are complicated by:

Significant emotional or behavioral disorder such as depression, anxiety, etc.

Exaggeration, inconsistent findings, subjective complaints out of proportion to objective findings, bizarre or contradictory observations

Work-related issues (please describe if known)_____________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Other (please describe) _________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Rehabilitation:

a) Is patient a suitable candidate for medical rehabilitation services?

Yes

No

 

b) Is patient a suitable candidate for vocational rehabilitation?

Yes

No

c)If yes, please specify _________________________________________________________________________________________

______________________________________________________________________________________________________________

Additional comments ______________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Name of attending physician (pleas e print)

Specialty

Telephone no. (including area code)

 

 

(

)

 

 

 

 

 

Address (number, s treet, city, province, pos tal code)

 

Fax no. (including area code)

 

 

(

)

 

 

 

 

 

Signature

MD.

 

Date (day, month, year)

Submit to: The Canada Life Assurance Company, Group Creditor Disability/Life Claims Department 330 University Avenue, Toronto ON M5G 1R8

Telephone (416) 597-1440 Toll free no. 1-800-387-4492 Fax no. (416) 552-6557