Service Canada Medical Report Form – Fill Out and Use This PDF

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

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

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

SC ISP-2519 (2018-10-03) E

1 / 9

Disponible en français

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.

SC ISP-2519 (2018-10-03) E

2 / 9

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.

SC ISP-2519 (2018-10-03) E

3 / 9

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.

SC ISP-2519 (2018-10-03) E

4 / 9

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*

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

SC ISP-2519 (2018-10-03) E

5 / 9

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

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*

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

SC ISP-2519 (2018-10-03) E

6 / 9

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

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*

*If prognosis and/or frequency is unknown, please explain why in Section 7 - Other relevant information. For additional medical condition(s), please attach an extra sheet.

SC ISP-2519 (2018-10-03) E

7 / 9

Section 6 - Patient's employment situation

This section gathers information to assess current and future restrictions on the patient's ability to work.

1. Did you recommend to your patient that they stop working?

Yes, I recommended that the patient stop working as of (date):

No	YYYY-MM-DD
Not discussed

If you have indicated that your patient has a terminal medical condition, skip the rest of this section.

2.From a strictly medical standpoint, do you expect your patient to return to any type of work in the future? Yes (please complete questions 3 and 4, below)

No (skip to Section 7)

Unknown (skip to Section 7)

3.If yes, please indicate when you expect your patient to return to work:

In 6 to 12 months

In 12 to 24 months

In more than 24 months

Unknown

4. If yes, please indicate what type of work you expect your patient will be able to do:

Usual work Modified work Another type of work that will require training Other:

Section 7 - Other relevant information

To help us evaluate the applicant's current and future ability to work, please add any other information you feel is relevant (e.g. planned investigations and/or specialist consultations, reason for unknown prognosis and/or frequency, etc.).

SC ISP-2519 (2018-10-03) E

8 / 9

Section 8 - Supporting documents

If you have supporting documents for any of the relevant medical conditions listed in Section 4 or Section 5, please include copies of these reports with this Medical Report.

Please identify the type of report(s) you are including:

longitudinal clinical notes

medical investigation report(s)

specialist's report(s)

hospital discharge report(s) other (please specify):

Section 9 - Declaration

I confirm that, to the best of my knowledge all of the information I have provided in this report is accurate and complete. I am a:

general practice physician or physician certified in family medicine (CCFP)

other physician specialist (please specify):

nurse practitioner

registered nurse in a geographically isolated community (not urban or rural)

Name	Address and telephone number
	(Please print or use a stamp)
Signature
X
Date (YYYY-MM-DD)

Where to send the completed Medical Report

Mail the completed Medical Report and supporting documents to the Service Canada location that serves the province/territory where your patient resides (see a list of addresses on the next page). Please remove the annexes before mailing the Medical Report.

For patients currently living outside Canada

Mail the completed Medical Report to the office serving the province/territory where the patient last lived. If unsure, please verify with the patient. Please remove the annexes before mailing the Medical Report.

SC ISP-2519 (2018-10-03) E

9 / 9

Annex A - List of grave medical conditions

The following list of severe and rapidly progressive medical conditions was developed based on extensive research by Employment and Social Development Canada. These conditions with marked and severe functional limitations have a high probability of meeting the CPP disability benefit eligibility criteria, and may result in death. For that reason, applications from patients with any of these conditions receive expedited processing.

1.Acute Lymphoid Leukemia

2.Adrenal Cancer

3.Alzheimer's Disease: Early Onset (less than age 60)

4.Amyloidosis

5.Amyotrophic Lateral Sclerosis (ALS)

6.Anal Cancer

7.Brain Cancer

8.Chronic Kidney Disease (Stage 4 or later)

9.Chronic Liver Disease

10.Colorectal Cancer

11.Esophagus Cancer

12.Frontotemporal Dementia

13.Gallbladder Cancer and Cancer of the Bile Ducts/Malignant Neoplasm of the Gallbladder and Extrahepatic Bile Ducts

14.Huntington's Chorea Disease

15.Progressive Polyneuropathy

16.Idiopathic Pulmonary Fibrosis (IPF)/Idiopathic Fibrosing Aleveolitis/Idiopathic Interstitial Pneumonia

17.Kidney Cancer

18.Liver Cancer

19.Lung Cancer/Carcinoma of the Lung/Malignant Neoplasm of the Trachea, Bronchus and Lung

20.Malignant Melanoma

21.Malignant Tumours of Small Intestine, including Duodenum

22.Multiple Myeloma

23.Muscular Dystrophy (Adult Onset)

24.Ovarian Cancer

25.Pancreatic Cancer

26.Paranoid Schizophrenia, Chronic Undifferentiated

27.Parkinson's Disease

28.Post-inflammatory Pulmonary Fibrosis/Interstitial (Non-idiopathic) Pulmonary Fibrosis

29.Primary Cerebellar Degeneration/Unspecified Types of Cerebellar Ataxia

30.Stomach Cancer

31.Thymus Cancer

32.Vascular Dementia

SC ISP-2519 (2018-10-03) E

Annex B - Examples of functional limitations

Physical abilities

Includes restrictions related to:

-changing body position (e.g. kneeling or squatting)

-maintaining body position (e.g. remaining seated or standing)

-fine hand use (e.g. turning a dial or knob)

-hand and arm use (e.g. throwing or catching an object)

-walking (forward, backward, or sideways)

-moving around (e.g. climbing or running around obstacles)

-using transportation (e.g. as a passenger in a taxi or on a bus or subway)

-using a computer (e.g. being able to look at a computer screen for at least 20 minutes)

Behaviours and emotional abilities

Includes restrictions related to:

-basic interpersonal interactions (e.g. showing respect and tolerance)

-complex interpersonal interactions (e.g. regulating emotions and impulses)

-maintaining formal relationships (e.g. with employers or service providers)

-handling stress and other psychological demands

Communication and thinking abilities

Includes restrictions related to:

-making conversation (e.g. with known individuals or strangers)

-acquiring new skills (e.g. learning to use a computer or tool)

-focusing attention (e.g. filtering out distracting noises)

-thinking (e.g. sequencing thoughts in a structured, logical manner)

-making decisions (e.g. identifying and choosing among several options)

-literacy

-numeracy

Other daily abilities

Includes restrictions related to:

-toileting

-dressing

-looking after one's health (e.g. taking medication as directed)

-using communication devices (e.g. using the telephone)

-acquiring goods and services

-maintaining economic self-sufficiency (e.g. managing money)

-doing housework

-preparing meals

-driving

SC ISP-2519 (2018-10-03) E

Annex C - Examples for Section 5

Medical condition: The name of the disease or disease state, diagnosis.

ICD code: International Classification of Diseases diagnosis code (version ICD-9-CM).

Impairment: Any loss or abnormality of psychological or anatomical structure or function.

Functional limitation: Restriction in activities and social participation directly or indirectly due to the impairment.

Example 1

Medical condition: Degenerative disc disease of lumbar spine with radiculopathy

ICD-9-CM code (XXX.X): 722.5

Date of symptom onset (YYYY-MM): 2008-03

Impairment(s):

-Advanced disc degeneration (see attached imaging study)

-Reduced range of motion

-Decreased strength

-Marked pain and fatigue

Functional limitation(s):

-Inability to sit, stand, or walk for more than 20 minutes

-Unable to lift more than 5 pounds

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		Actual/proposed		Actual/estimated			Response
and frequency		start date		end date			(e.g. efficacy, side effects etc.)
		(YYYY-MM)		(YYYY-MM)			and other remarks
Flexeril 10 mg BID		2018-01		2018-02		Discontinued due to GI upset and
						dizziness
Naprosyn 375 mg BID		2018-02		Ongoing		Limited pain relief for two hours
Type and frequency of		Actual/proposed		Actual/estimated			Response
other treatment(s)		start date		end date			(e.g. efficacy, side effects etc.)
		(YYYY-MM)		(YYYY-MM)			and other remarks
Surgery		2017-06				Ineffective in resolving pain; refer to
						attached surgical and MRI reports
Referral to pain clinic in 2018-01		Pending
(18 month waiting list)

SC ISP-2519 (2018-10-03) E

Annex C - Examples for Section 5

Example 2

Medical condition: Major depression, recurrent

ICD-9-CM code (XXX.X): 296.3

Date of symptom onset (YYYY-MM): 2010-01

Impairment(s):

-Severe mood disturbance

-Labile emotions

-Psychomotor slowing

-Fatigue resulting from insomnia

-Weight gain of 30 lbs. in the last 6 months

Functional limitation(s):

- Difficulty maintaining focus on work task and in meeting deadlines

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		Actual/proposed		Actual/estimated			Response
and frequency		start date		end date			(e.g. efficacy, side effects etc.)
		(YYYY-MM)		(YYYY-MM)			and other remarks
Cipralex 10-20 mg		2017-06		2017-12		Started at 10 mg, increased to 15 mg,
						then 20 mg with no improvement
Pristiq 50 mg OD, 2 month trial		2018-01		Trial ongoing		Occasional dizziness and dry mouth
anticipated
Wellbutrin XL 150 mg, 2 month trial		2018-01		Trial ongoing
anticipated
Type and frequency of		Actual/proposed		Actual/estimated			Response
other treatment(s)		start date		end date			(e.g. efficacy, side effects etc.)
		(YYYY-MM)		(YYYY-MM)			and other remarks
Psychotherapy (treated monthly by		2018-01		Ongoing		See attached psychiatrist report
psychiatrist)
Addictions counseling (treated		2018-01		Ongoing		See attached social worker's clinical
monthly by social worker)						assessment notes
Electroconvulsive therapy						If depression becomes resistant to other
						treatment

SC ISP-2519 (2018-10-03) E