Service Canada Medical Report Form PDF Details

Applying for a Canada Pension Plan (CPP) disability benefit is a critical process for those unable to work due to severe and prolonged mental and/or physical impairments. Integral to this application is the Service Canada Medical Report form, a comprehensive document designed to capture the intricate details of an applicant's medical condition and its impact on their ability to work. Applicants are tasked with completing the initial sections of this form, including personal information and consent for Service Canada to obtain further personal information. A pivotal aspect of the process involves the applicant's healthcare provider—either a doctor or nurse practitioner—who must fill out detailed sections regarding the diagnosis, functional limitations, prognosis, and treatment of the condition. This form serves not only as a critical piece of the determination process for CPP disability benefits but also as a means to ensure that the applicant's condition is thoroughly documented and understood. It highlights the necessity of keeping the patient's medical history and the substantial effect of their condition on employability at the forefront of the application. In addition, it underscores the importance of submitting the application expediently, as the date of reception by Service Canada can influence benefit commencement. The provision by Service Canada to cover up to $85 for the report's completion fee underscores the acknowledgment of the financial burden associated with medical documentation. Lastly, the document sheds light on the specific provisions for those with terminal or grave conditions, offering expedited processing to ensure timely support for those in dire need.

QuestionAnswer
Form NameService Canada Medical Report Form
Form Length14 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 30 sec
Other namescpp medical report, medical report for a canada pension plan disability benefit, cpp disability forms pdf, cpp disability medical form

Form Preview Example

PROTECTED B (when completed)

Personal Information Bank ESDC PPU 146

Medical Report

for a Canada Pension Plan Disability Benefit

Instructions for the applicant/patient - please read carefully

An application and a medical report are needed by Service Canada to determine if you qualify for a Canada Pension Plan (CPP) disability benefit.

You (the applicant) must:

ьcomplete the Application for a Canada Pension Plan Disability Benefit (ISP1151). The application can be found at www.canada.ca/esdc-forms.

ьfill out Section 1 and Section 2 of this Medical Report.

ьwrite your Social Insurance Number at the top of each page of this Medical Report.

Your doctor or nurse practitioner must complete Sections 3 to 9 of the Medical Report, sign it, and send it to Service Canada.

DO NOT WAIT for your doctor or nurse practitioner to complete the Medical Report before sending your completed application to Service Canada. The date Service Canada receives your application could affect when your benefit starts.

Service Canada will help you pay for the cost of the Medical Report by paying up to $85.00 directly to your doctor or nurse practitioner. Any money owing over this amount is your responsibility.

Section 1 - Information about you

Social Insurance Number

 

 

Preferred language

 

 

 

 

 

 

English

French

Optional:

Mr.

Mrs.

Miss

Ms.

 

 

First name

 

 

Middle name

Last name(s)

 

FOR OFFICE USE ONLY

Date Stamp

Date of birth (YYYY-MM-DD)

Last name at birth (if different from above)

Mailing address (No., Street, Apt., PO Box, RR), City/Town, Province/Territory, Country (if not Canada), Postal code

Telephone number

Alternate telephone number

The best time for Service Canada to contact you

Morning

Afternoon

Please don't call, send letters only

Service Canada delivers Employment and Social Development Canada

programs and services for the Government of Canada

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Disponible en français

Social Insurance Number:

PROTECTED B (when completed)

Section 2 - Consent for Service Canada to obtain personal information

The consent for Service Canada to obtain personal information must be completed and returned with this Medical Report. Your doctor or nurse practitioner can make a photocopy of this consent for their records.

Service Canada is authorized under Section 68 and 69 of the Canada Pension Plan (CPP) Regulations to receive personal information (medical and non-medical) about you to determine if you qualify or continue to qualify for CPP disability benefits. Your consent to permit Service Canada to obtain this information is necessary, should Service Canada need this information from persons and organizations listed below.

I give Service Canada my consent to obtain personal information about me that would help determine if I qualify or continue to qualify for CPP disability benefits. For this reason, Service Canada may contact any of the following persons and organizations if necessary:

-medical doctors, nurse practitioners, consultant specialists, or other health care professionals

-educational institutions or other vocational agencies

-my accountant or bookkeeper for information on self-employment

-federal, provincial, territorial, or municipal government departments and agencies

-provincial or territorial workers' compensation boards

-financial institutions (for address updates only)

-medical facilities or hospitals

-administrators of insurance plans

-employers, former employers

-voluntary organizations

-employees (for cases of self-employed persons)

Note: Failure to check an option below could result in a delay in processing your application.

I give my consent to Service Canada to obtain medical and other personal information about me from all persons and organizations listed above. I understand that this information may help determine if I qualify or continue to qualify for CPP disability benefits.

I do not give my consent to Service Canada to obtain medical and other personal information about me from all persons and organizations listed above.

I understand that if I do not give my consent, Service Canada:

-will make a decision based on the available information on my file;

-may stop paying me the benefits if I am already receiving them; and

-can require that I provide the necessary information.

Signature of applicant / authorized representative

Date (YYYY-MM-DD)

X

To be completed by a witness only if the applicant signs with a mark (e.g. X).

I have read the contents of this section to the applicant, who appeared to fully understand them and who made their mark in my presence.

First name of witness (print)

Middle name

Last name(s)

Telephone number

 

 

 

 

Witness signature

 

 

Date (YYYY-MM-DD)

X

 

 

 

 

 

 

 

This signed consent is valid for up to 3 years unless you cancel it in writing. Service Canada requires your original

signature, but we will use a photocopy and consider it as valid as the original when requesting personal

information from the persons and organizations listed above.

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Social Insurance Number:

PROTECTED B (when completed)

Sections 3 to 9 must be completed by a doctor or nurse practitioner

Instructions

Your patient is applying for a Canada Pension Plan (CPP) disability benefit. To help us determine if they are eligible, please complete this form on their behalf. Note that we may contact you if we require additional information.

Under CPP legislation, Service Canada is responsible for deciding if a person is disabled. According to the legislation, a disability must be a mental and/or physical impairment(s) that is both severe and prolonged.

-Severe means that a person has a mental and/or physical disability that regularly stops them from doing any type of substantially gainful work/occupation; and

-Prolonged means that the disability is long-term and of indefinite duration or is likely to result in death.

The legal test for CPP disability is one of medical impairment and employability. In other words, does the severe and prolonged disability prevent the person from working at any job? To decide if the disability meets this legal test, Service Canada looks at the combined impact of:

-the objective medical findings;

-the functional limitations, as reported by both the patient and their health care professional; and

-the person's age, education, and work experience.

Access to personal information

Pursuant to the Privacy Act, upon written request, Service Canada is obligated to provide the applicant or their representative with any information or records, including medical reports, contained in their file (Personal Information Bank ESDC PPU 146). For more information regarding the Privacy Act, you can consult Info Source at www.infosource.gc.ca.

Compensation

To compensate you for completing the report, Service Canada will pay up to $85 directly to you. To ensure prompt payment, submit the completed report and your invoice as quickly as possible.

Your invoice must include the patient's name, address, and identification number. For income tax purposes, your invoice must also include one of the following:

-your Business Number (BN); or

-your Goods and Services Tax (GST) / Harmonized Sales Tax (HST) number; or

-your Social Insurance Number (SIN).

Without the appropriate numbers, your medical invoice cannot be processed.

Without this information, you and/or Service Canada may be subject to a fine as noted in the Income Tax Act, paragraph 221(1).

Submitting the Medical Report

Please return the completed report directly to Service Canada. If you send us the report on your patient's behalf, please advise them.

A delay in the completion of this medical report may affect your patient's entitlement to benefits due to lack of medical information.

If you have any questions, contact Service Canada at 1-800-277-9914 (TTY users: 1-800-255-4786).

To retain a copy of the Consent for Service Canada to obtain personal information (Section 2) for your records, please make a photocopy and return the original with the completed Medical Report. If you require an original signature, the form (ISP2502) can be found at www.canada.ca/esdc-forms.

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Social Insurance Number:

PROTECTED B (when completed)

Section 3 - Duration of relationship with the patient

This information will help Service Canada confirm that we have the patient's complete medical history.

How many years has this patient been in your care?

1 year or less

1 to 2 years

3 to 4 years

5 years or more

Number of times this patient has visited your office in the past 12 months:

Date of last office visit (YYYY-MM-DD):

Date you first started treating this patient's primary medical condition (YYYY-MM-DD):

Section 4 - Expedited processing for terminal and grave conditions

This section should be completed ONLY if your patient has been diagnosed with a terminal illness or one of the 32 grave conditions listed in Annex A. If your patient does not have a terminal illness or a grave condition, skip to Section 5 - Medical conditions, impairments, functional limitations and treatment.

Applications from patients with a terminal illness or a grave condition receive priority handling. In these cases, once we receive a complete application, including the Medical Report, our goal is to determine the applicant's eligibility for CPP disability benefits within 5 business days for applicants with a terminal illness and 30 calendar days for those with a grave condition.

Does your patient have a medical condition that is:

a)Terminal - for the purpose of CPP, terminal is defined as a disease state that cannot be cured or adequately treated and is reasonably expected to result in death within 6 months.

Yes - (provide details below)

Diagnosis

ICD-9-CM code

Date of symptom onset

(XXX.X)

(YYYY-MM)

 

 

 

 

 

 

 

If the patient has other non-terminal medical conditions that prevent them from regularly working at any job, please provide details in Section 5 - Medical conditions, impairments, functional limitations and treatment. Otherwise, please skip to Section 6 - Patient's employment situation.

OR

b)Grave - for the purpose of CPP, grave is defined as a condition that is included in the list of 32 severe and rapidly progressive medical conditions in Annex A.

Yes (provide details in Section 5 - Medical conditions, impairments, functional limitations and treatment)

Section 5 - Medical conditions, impairments, functional limitations and treatment

This section collects information about the medical condition(s), the associated impact on the patient's functional abilities, and the expected course of illness.

See Annex B for examples of functional limitations and Annex C for examples on completing this section.

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Social Insurance Number:

PROTECTED B (when completed)

Section 5 - Medical conditions, impairments, functional limitations and treatment

Please use one page per medical condition. List the medical conditions in order of greatest functional impact.

Medical condition:

ICD-9-CM code (XXX.X):

Date of symptom onset (YYYY-MM):

Impairment(s):

Functional limitation(s):

Prognosis

 

 

 

 

Condition is likely to:

improve

deteriorate

remain the same

unknown*

Expected duration:

less than 1 year

more than 1 year

 

Frequency:

recurrent/episodic

continuous

unknown*

 

Medication(s), dosage

and frequency

Actual/proposed

start date (YYYY-MM)

Actual/estimated

end date

(YYYY-MM)

Response

(e.g. efficacy, side effects etc.)

and other remarks

Type and frequency of

other treatment(s)

Actual/proposed

start date (YYYY-MM)

Actual/estimated

end date

(YYYY-MM)

Response

(e.g. efficacy, side effects etc.)

and other remarks

* If prognosis and/or frequency is unknown, please explain why in Section 7 - Other relevant information.

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As for the fields of this particular document, here's what you should consider:

1. First, while completing the medical report for cpp disability benefit, beging with the page with the following blanks:

Filling in section 1 of cpp disability application form

2. The next part would be to complete these particular fields: Social Insurance Number, PROTECTED B when completed, Section Consent for Service, and Service Canada is authorized under.

Filling in part 2 in cpp disability application form

3. The following segment is considered pretty uncomplicated, I give my consent to Service, I do not give my consent to, I understand that if I do not give, will make a decision based on the, Signature of applicant authorized, Date YYYYMMDD, To be completed by a witness only, First name of witness print, Middle name, Last names, and Telephone number - these empty fields has to be filled out here.

Completing part 3 in cpp disability application form

4. This next section requires some additional information. Ensure you complete all the necessary fields - Witness signature X, Date YYYYMMDD, This signed consent is valid for, signature but we will use a, information from the persons and, and SC ISP E - to proceed further in your process!

Step # 4 for filling out cpp disability application form

5. As you near the last parts of this form, you will find just a few more points to do. Notably, Social Insurance Number, PROTECTED B when completed, Sections to must be completed by, Instructions Your patient is, Severe means that a person has a, substantially gainful, Prolonged means that the, The legal test for CPP disability, the objective medical findings, and Access to personal information should be filled out.

cpp disability application form writing process described (portion 5)

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