Canadian medical forms
The forms Canadian clinicians fill, by province.
1000 requisitions, disability and insurance claims, workers' compensation reports, drug coverage requests, and driver medicals. Each one lists who completes it, who issues it, and where to get the current official version.
Checked October 2026
No forms match. Try a form number or the issuer's name.
Federal and national
Insurance claims
-
Equitable Life's attending physician statement for a disability claim. The insured signs the authorization in Part 1 and the attending physician completes Part 2.
- Completed by
- Owner or insured (Part 1); attending physician (Part 2)
- Issued by
- The Equitable Life Insurance Company of Canada
- Format
- Fillable PDF
- Language
- English
-
Equitable Life's physician statement for a compassionate advance on a life insurance policy. The patient signs the authorization in Part 1 and the attending physician completes Part 2.
- Completed by
- Patient (Part 1); attending physician (Part 2)
- Issued by
- The Equitable Life Insurance Company of Canada
- Format
- Fillable PDF
- Language
- English
-
Empire Life's physician statement for a group short term disability claim. The employee completes the information and consent section, and the attending physician completes the statement.
- Completed by
- Employee (information and consent); attending physician (statement)
- Issued by
- The Empire Life Insurance Company (Group Solutions)
- Format
- Fillable PDF
- Language
- English
- KNEEB-110
Authorization Form for Custom Braces
Green Shield Canada's prior approval form for a custom brace. The patient or guardian completes Section I and the treating physician prescribes and justifies the brace in Section II.
- Completed by
- Patient or guardian (Section I); treating physician (Section II)
- Issued by
- Green Shield Canada
- Format
- Fillable PDF
- Language
- English and French
-
Green Shield Canada's prior approval form for prosthetic appliances and durable medical equipment. The patient or guardian completes Section I and the physician prescribes the items in Section II.
- Completed by
- Patient or guardian (Section I); physician (Section II)
- Issued by
- Green Shield Canada
- Format
- Fillable PDF
- Language
- English and French
-
iA Financial Group's travel claim for trip cancellation or interruption, processed by CanAssistance. The policyholder completes the claim form and the ill or injured person's physician completes the Attending Physician Declaration.
- Completed by
- Policyholder (claim form); physician of the ill or injured person (Attending Physician Declaration)
- Issued by
- iA Financial Group, claims handled by CanAssistance
- Format
- Fillable PDF
- Language
- English
-
Demande de prestation pour une maladie grave, déclaration du médecin traitant
Desjardins Insurance's physician statement for a critical illness claim on individual, GetWell or group coverage. The insured completes Section A, and the attending physician or diagnosing specialist completes Sections B to E.
- Completed by
- Insured (Section A); attending physician or diagnosing specialist (Sections B to E)
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
- 83730
Disability Claim Form
RBC Life Insurance Company's claim package for disability and waiver of premium claims. The claimant, the employer, and the attending physician each complete their own statement.
- Completed by
- Claimant (Claimant's Statement and patient's information); employer (Employer's and Occupation Statements); attending physician (Attending Physician's Statement of Disability)
- Issued by
- RBC Life Insurance Company
- Format
- Fillable PDF
- Language
- English
-
iA Financial Group's form for continuing an approved disability claim. The member updates their statement and the attending physician completes the physical or psychological statement.
- Completed by
- Member (Member's Statement and member identification); attending physician (physical or psychological statement)
- Issued by
- iA Financial Group (Industrial Alliance Insurance and Financial Services Inc.)
- Format
- Fillable PDF
- Language
- English
-
iA Financial Group's initial claim for short-term disability, long-term disability, or waiver of premium. The employer and the member complete their statements, and the attending physician completes the physical or psychological statement.
- Completed by
- Policyholder (Policyholder's Statement); member (Member's Statement and member identification); attending physician (physical or psychological statement)
- Issued by
- iA Financial Group (Industrial Alliance Insurance and Financial Services Inc.)
- Format
- Fillable PDF
- Language
- English
- INS-2944B
Disability Credit Protect Claim Package
Empire Life's claim package for the Disability Credit Protect monthly benefit. The claimant and life insured complete the claimant's statement and Section 1 of the physician's statement, and the attending physician completes Sections 2 to 13.
- Completed by
- Claimant and life insured (claimant's statement and physician's statement Section 1); attending physician (Sections 2 to 13)
- Issued by
- The Empire Life Insurance Company (Retail Claims)
- Format
- Fillable PDF
- Language
- English and French
- AICC10365RBC-2
Group Critical Illness Claim Form and Instructions
The claim form for RBC group critical illness coverage, administered by Allstate. The insured completes the claimant pages and the attending physician completes the Attending Physician's Statement.
- Completed by
- Insured (Insured and Patient Information, benefit selection and authorization); attending physician (Attending Physician's Statement)
- Issued by
- RBC Insurance, administered by Allstate Insurance Company of Canada
- Format
- Fillable PDF
- Language
- English
-
Déclaration initiale du médecin traitant
Desjardins Insurance's initial physician statement for a group disability claim, with a physical illness version and a psychological illness version. The employee completes Section 1 and the attending physician completes the rest.
- Completed by
- Employee (Section 1); attending physician (Sections 2 to 6)
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
-
The Canadian life and health insurance industry's standard medical statement for starting a disability claim. The patient completes Section 1 and the doctor or other medical provider completes Section 2.
- Completed by
- Patient (Section 1); doctor or applicable medical provider (Section 2)
- Issued by
- Canadian Life and Health Insurance Association (CLHIA)
- Format
- Fillable PDF
- Language
- English and French
-
Medavie Blue Cross's medical statement for a new disability claim. The patient completes Section 1 and the doctor or other medical provider completes the medical statement in Section 2.
- Completed by
- Patient (Section 1); doctor or other medical provider (Section 2)
- Issued by
- Medavie Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Canada Life's one-page supplementary disability form for a balance protection (creditor) insurance claim. The claimant completes the claimant's statement and authorization, and the attending physician completes a short statement.
- Completed by
- Claimant (claimant's statement and authorization); attending physician (attending physician's statement)
- Issued by
- The Canada Life Assurance Company (Creditor Insurance)
- Format
- Fillable PDF
- Language
- English
- 490SC-AS-HH-P-E
Accommodation Services - Attending Physician Statement
Services d’aménagement des conditions de travail – Déclaration du médecin traitant
Provides medical information supporting a referral for workplace accommodation and stay-at-work support.
- Completed by
- Attending physician
- Issued by
- Sun Life
- Format
- Language
- English and French
- 02026A
Additional Report of Attending Physician
Updates the insurer on an ongoing group disability claim, with separate versions for physical and psychological illness.
- Completed by
- Attending physician
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English
- M7537
Application for Dependant with a Disability Coverage
Applies to keep workplace benefits going for a dependant past the age limit because of a disability.
- Completed by
- Physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- GL0514E
Application for Over-age Dependant Requiring Special Attention Coverage
Applies to keep covering a plan member's dependant beyond the age limit on account of disability, and the attending physician provides the medical evidence in Section 4.
- Completed by
- Attending physician (Section 4); plan administrator completes Section 1 first; plan member completes Sections 2, 3 and 5
- Issued by
- Manulife
- Format
- Fillable PDF
- Language
- English
- GL2439
Attendance Support Program – Attending Physician Statement
Supports early absence management by having the treating physician describe an employee's condition when a group plan flags repeated or growing time away from work.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Fillable PDF
- Language
- English
- 01CAN0100A
Attending Physician Declaration – Trip Cancellation
Supports a travel insurance claim for cancelling, interrupting or cutting short a trip because someone fell ill or was injured.
- Completed by
- Attending physician of the ill or injured person
- Issued by
- CanAssistance (claims administrator for Blue Cross and other travel plans)
- Format
- Language
- English
-
Attending Physician Statement
Supports an individual disability insurance claim, though the insurer directs physicians to the industry statement instead.
- Completed by
- Attending physician
- Issued by
- RBC Insurance
- Format
- Language
- English
-
Attending Physician Statement
Opens a group long term, short term or waiver-of-premium claim by setting out the patient's diagnosis, limitations and treatment for the insurer.
- Completed by
- Attending physician or other medical provider
- Issued by
- Wawanesa Life
- Format
- Language
- English
- FORM-149E
Attending Physician’s Statement – Critical Condition Benefit
Supplies the statement from the attending physician needed for a claim under a group critical condition benefit.
- Completed by
- Attending physician
- Issued by
- Medavie Blue Cross
- Format
- Fillable PDF
- Language
- English
- 801490
Attending Physician's Statement of Disability (Business Credit Living Benefit Insurance - Disability, Part B)
Provides the physician's Part B medical statement in a disability claim for TD business credit insurance, after the patient completes Section 1.
- Completed by
- Licensed medical practitioner (patient completes and signs Section 1)
- Issued by
- TD Insurance (creditor) / Canada Life
- Format
- Fillable PDF
- Language
- English
- M4442
Certificate of Attending Physician – Dismemberment or Loss
Certifies an accidental dismemberment or specific loss so an individual insurance claim for it can go forward.
- Completed by
- Attending physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- F54-380A
Claim form – Accidental dismemberment
Réclamation – Mutilation accidentelle
Claims group accidental dismemberment benefits and includes a section for the attending physician's statement on the loss.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Language
- English and French
- F54-856A
Claim Form – Critical Illness
Réclamation – Maladie grave
Claims group critical illness benefits and includes a section for the attending physician's statement on the diagnosis.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Language
- English and French
- F54-361A
Claim form – Life insurance
Réclamation – Assurance vie
Claims group life benefits after a death, with a physician's statement required above certain coverage amounts.
- Completed by
- Physician
- Issued by
- iA Financial Group
- Format
- Fillable PDF
- Language
- English and French
- 512152
Claim package for TD Protection Plan Disability Insurance (Loan/Mortgage)
Supports a disability claim on loans and mortgages insured through TD Protection Plan, where the clinician completes Part B of the package.
- Completed by
- Family physician, consulting specialist or other applicable medical provider
- Issued by
- TD Insurance (creditor) / Canada Life
- Format
- Fillable PDF
- Language
- English
- NN0625E
Claims for Disability Benefit - Living Benefits (Standard Statement of Accident or Illness for Disability Insurance)
Demande de prestations d'invalidité - Prestations du vivant
Claims a disability benefit under a life insurance policy, combining the claimant's statement with the attending physician's sections.
- Completed by
- Insured person (pages 1-8 and APS Section 1); attending physician (APS sections 2-13)
- Issued by
- Manulife
- Format
- Fillable PDF
- Language
- English and French
- 307 CAN
Commercial Credit Statement of Claim Form – Claim for Disability: Attending Physician's Statement
Backs a disability claim on Scotiabank's commercial credit insurance, and the physician fills out the attending physician's statement that is attached.
- Completed by
- Attending physician
- Issued by
- ScotiaLife Financial / Canada Life (creditor)
- Format
- Fillable PDF
- Language
- English
- 09296E
Confirmation of a dependent child's functional impairment
Confirmation de la déficience fonctionnelle d’un enfant à charge
Confirms that a dependent child has a functional impairment, allowing the family to keep their group insurance coverage in place.
- Completed by
- Child's attending physician
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
- GL2325
Critical Disease Physician Statement
Gives the insurer a general physician account of the diagnosis behind a group critical disease claim when no condition-specific statement applies.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Fillable PDF
- Language
- English
- 17026A
Critical illness claim – Attending physician's statement
Déclaration du médecin traitant pour une maladie grave
Provides the attending physician's statement that supports a critical illness claim, completed when the patient files for the benefit.
- Completed by
- Attending physician
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
- 83712
Critical Illness Claim – Confidential Physician’s Statement (condition-specific)
Provides a confidential physician's statement for an individual critical illness claim, with separate versions for conditions such as cancer and cardiovascular disease.
- Completed by
- Attending physician
- Issued by
- RBC Insurance
- Format
- Fillable PDF
- Language
- English
-
Critical illness physician statements (condition-specific)
Gathers the medical details a group critical illness claim needs for a specific diagnosis, with separate versions for covered illnesses in dependent children.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Language
- English
-
Critical Illness Physician Statements (condition-specific)
Covers the many diagnosis-specific statements a group critical illness claim can require, with 33 versions so the physician answers questions for the right condition.
- Completed by
- Attending physician
- Issued by
- Wawanesa Life
- Format
- Language
- English
- 2002000-029A-CL
Custom Knee Brace Questionnaire
Gets approval for a custom knee brace before the estimate is accepted, using the physician's current medical information.
- Completed by
- Physician (current medical information); supplier completes purchase information
- Issued by
- ClaimSecure
- Format
- Fillable PDF
- Language
- English
- 14153E
Death claim – Physician's statement
Déclaration du médecin traitant pour un décès
Gives the physician's statement needed to process a group life claim after a death.
- Completed by
- Attending physician
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
- F54-382A
Disability – Extension request
Invalidité – Demande de prolongation
Asks to extend a group disability claim, and the physician describes the patient's present situation, treatment, follow-up, prognosis, restrictions and limitations.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Fillable PDF
- Language
- English and French
- F54-381A
Disability – Initial request
Invalidité – Demande initiale
Opens a group disability claim for physical or psychological illness, with sections for the member, the employer and the attending physician.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Fillable PDF
- Language
- English and French
- 5534
Disability Insurance Claim
Supports a disability claim on CIBC creditor insurance, with the clinician filling in the embedded industry medical statement.
- Completed by
- Family physician, consulting specialist or other applicable medical provider
- Issued by
- CIBC creditor insurance / Canada Life
- Format
- Fillable PDF
- Language
- English
- Form 2274
Disability Insurance medical statement
Starts a group disability claim with the insurer's version of the industry medical statement.
- Completed by
- Attending physician or other medical provider
- Issued by
- Equitable Life
- Format
- Fillable PDF
- Language
- English
-
Disability Supplementary Medical Information Physician Statement
Updates a group disability claim already in progress with newer clinical findings, so the insurer can decide whether benefits continue.
- Completed by
- Physician
- Issued by
- Wawanesa Life
- Format
- Fillable PDF
- Language
- English
-
Dismemberment Physician Statement
Documents the loss behind an accidental dismemberment benefit under a group plan, completed by the physician treating the injury.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Language
- English
- GL2554-EI
Early Intervention – Attending Physician’s Statement for Mental Health Conditions
Reports a mental health condition to a group early intervention program, so support can begin before a full disability claim is needed.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Fillable PDF
- Language
- English
- 490-PS-E
Election of method of settlement and statement of claim: Physician statement
Choix du mode de règlement et déclaration de sinistre : Déclaration du médecin
Gives the physician's statement that goes with a group life claim after a death.
- Completed by
- Attending physician
- Issued by
- Sun Life
- Format
- Language
- English and French
- GL2647
Functional Abilities
Records what a patient can and cannot do physically and mentally, which the insurer uses to assess a disability claim and plan a return to work.
- Completed by
- Treating physician or other health professional
- Issued by
- The Co-operators
- Format
- Fillable PDF
- Language
- English
- GRP-3918-EN
Gender Affirmation Pre-Authorization Form
Asks for pre-authorization of gender affirmation procedures under a group plan, and a specialist or other qualified practitioner completes it.
- Completed by
- Specialist (physician or qualified medical practitioner)
- Issued by
- Empire Life
- Format
- Fillable PDF
- Language
- English
- M7540
Gender Affirmation Procedure Application
Requests pre-approval before each gender affirmation procedure, completed by a qualified provider who need not be a physician in Quebec.
- Completed by
- Attending physician or other qualified healthcare provider (in Quebec, need not be a physician)
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
-
Group insurance forms
Directs a clinician to a group insurer's claim forms, which include attending physician statements and appear only after a group or policy number is entered.
- Completed by
- Attending physician (for the medical statements in the package)
- Issued by
- Beneva
- Format
- Sent for each case
- Language
- English and French
- GLB-0055-EN
Group Life and Accidental Death Insurance Claim Form
Claims group life or accidental death benefits, and includes a statement to be completed by the attending physician.
- Completed by
- Attending physician
- Issued by
- Empire Life
- Format
- Fillable PDF
- Language
- English
- M63
Group Life Benefits – Attending Physician’s Certificate of Death
Certifies that a death occurred and what caused it, so that a claim on workplace group life insurance can be paid.
- Completed by
- Attending physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- Bilingual
- 09008E
Home nursing care - Request for additional information
Soins infirmiers à domicile - Demande de renseignements supplémentaires
Provides the clinical details that an insurer requests in order to back up a claim for nursing care at home.
- Completed by
- Attending health care professional
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
- 2002000-021A-CL-64
Hospital Bed Assessment Form
Gets approval before a plan pays to buy or rent a hospital bed, with the physician giving current medical information.
- Completed by
- Physician (current medical information); supplier completes purchase/rental information
- Issued by
- ClaimSecure
- Format
- Fillable PDF
- Language
- English
-
Individual life insurance claims
Marks the physician statements inside an individual life or critical illness claims package, which the insurer's claims team sends out on request rather than posting as one fixed form.
- Completed by
- Attending physician (for physician statements in the package)
- Issued by
- Wawanesa Life
- Format
- Sent for each case
- Language
- English
-
Initial Disability Insurance Medical Statement
Supports workplace short-term, long-term and early referral disability claims, and group life premium waiver claims, by linking the harmonized industry medical statement.
- Completed by
- Attending physician or other medical provider
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
-
Initial Disability Insurance Medical Statement
Déclaration médicale initiale pour l’assurance invalidité
Begins a disability claim, short-term or long-term, with any Canadian life and health insurer that takes part, using the statement the industry has standardized.
- Completed by
- Attending physician or other applicable medical provider (family physician, consulting specialist or other)
- Issued by
- CLHIA (harmonized industry form)
- Format
- Fillable PDF
- Language
- English and French
-
Initial Disability Insurance Medical Statement
Starts a group disability claim by giving the insurer the first medical picture of why the plan member cannot work.
- Completed by
- Attending physician or other medical provider
- Issued by
- The Co-operators
- Format
- Fillable PDF
- Language
- English
- 020255A
Initial Disability Insurance Medical Statement
Déclaration médicale initiale pour l’assurance invalidité
Opens an individual disability claim with the standard industry medical statement completed by the attending physician or another provider.
- Completed by
- Attending physician or other medical provider
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
-
Initial Disability Insurance Medical Statement
Starts a group short or long-term disability claim using the industry medical statement.
- Completed by
- Attending physician or other medical provider
- Issued by
- Empire Life
- Format
- Fillable PDF
- Language
- English
- GBF0002E
Initial Disability Insurance Medical Statement
Opens a short or long-term disability claim using the standard industry medical statement, one form for both.
- Completed by
- Attending physician or other medical provider
- Issued by
- Manulife
- Format
- Language
- English
- 5548-SL-IDIMS-E
Initial Disability Insurance Medical Statement
Déclaration médicale initiale pour l’assurance invalidité
Starts new claims for short-term, long-term and salary continuance disability, and takes the place of the insurer's earlier statement from the attending physician for new claims.
- Completed by
- Attending physician or other medical provider
- Issued by
- Sun Life
- Format
- Language
- English and French
-
Initial Disability Insurance Medical Statement
Supports a first-time long-term disability claim made through the federal public service disability plan, completed by the attending clinician.
- Completed by
- Attending physician (or applicable treating medical provider)
- Issued by
- Sun Life (federal Public Service Disability Insurance Plan)
- Format
- Language
- English
-
Initial Disability Insurance Medical Statement
Supports a first-time long-term disability claim for a federal public service management employee, completed by the attending physician.
- Completed by
- Attending physician or medical provider
- Issued by
- iA Financial Group (Public Service Management Insurance Plan)
- Format
- Language
- English
-
Life & Critical Illness claims
Points to BMO's life and critical illness claims, where the insurer sends the package and any physician statements once the claim has started.
- Completed by
- Attending physician (for physician statements in the package)
- Issued by
- BMO Insurance
- Format
- Sent for each case
- Language
- English and French
- GL2332
Life Waiver of Premium – Attending Physician Statement
Asks the treating physician to back a request to stop life insurance premiums while a plan member is disabled under group coverage.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Fillable PDF
- Language
- English
- F89681-BLOC
Loan/Line of Credit/RRSP Readiline/SRIL Disability Creditor Insurance - Attending Physician's Statement
Assurance-invalidité pour prêts, marges de crédit, MargExpress REER et prêts à tempérament semi-renouvelables Assurance-Crédit - Déclaration du médecin traitant
Supplies the attending physician's written statement backing a disability claim on a BMO loan, RRSP Readiline, line of credit or an instalment line that is semi-revolving.
- Completed by
- Attending physician
- Issued by
- BMO creditor insurance / Securian Canada
- Format
- Fillable PDF
- Language
- English and French
- GL2554-LTD
Long Term Disability – Attending Physician’s Statement for Mental Health Conditions
Provides the clinical detail for a long term disability claim based on a mental health condition, completed by the treating physician.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Fillable PDF
- Language
- English
- 6E
Long Term Disability Attending Physician's Statement (APS)
The treating physician's first statement supporting the long-term disability claim of a member of the Canadian Armed Forces who is being released.
- Completed by
- Treating physician
- Issued by
- SISIP Financial (Manulife)
- Format
- Fillable PDF
- Language
- English
-
Making a critical illness, accident-sickness or disability claim
Explains how claims for individual critical illness, accident and sickness, and disability coverage start, through an online request, since no physician statement PDFs are posted.
- Completed by
- Attending physician (claim documents supplied by Beneva)
- Issued by
- Beneva
- Format
- Sent for each case
- Language
- English and French
- 2002000-022A-CL-64
Nursing Care Assessment Form
Gets approval before a plan pays for private nursing care, with the physician supplying current medical information and the nursing agency its own part.
- Completed by
- Physician (current medical information); nursing agency/facility completes its part
- Issued by
- ClaimSecure
- Format
- Fillable PDF
- Language
- English
- M7532
Nursing Care Health Assessment Form
Assesses the patient before care starts so the plan can decide how much private nursing it covers.
- Completed by
- Physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- F54-898A
Nursing care questionnaire
Questionnaire pour les soins infirmiers
Backs a group health claim for nursing care paid for privately, using the physician's answers to the questionnaire.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Fillable PDF
- Language
- English and French
- F54-923A
Overage dependent with a disability questionnaire
Personne à charge ayant un handicap et dépassant l'âge maximal
Backs a request to keep group coverage for a dependent past the age limit because of a disability.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Language
- English and French
- 70-0734
Physician’s initial statement – Child critical illness claim
Gives the physician's first statement for a critical illness claim made on an insured child's individual policy.
- Completed by
- Attending physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- 70-0720
Physician’s initial statement – Critical illness claim
Gives the physician's first statement for a critical illness claim on an individual policy sold through an advisor.
- Completed by
- Attending physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- M7570
Physician’s initial statement – Group Critical Illness claim
Gives the physician's first statement for a workplace critical illness claim on an employee, spouse or child.
- Completed by
- Attending physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- 020265A
Physician's statement – Additional report
Déclaration du médecin traitant – Rapport supplémentaire
Updates the insurer on an ongoing individual disability claim with a follow-up report from the attending physician.
- Completed by
- Attending physician
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
-
Physician's Statement Group Life Insurance
Certifies a plan member's death and its cause so the insurer can settle a group life benefit.
- Completed by
- Attending physician
- Issued by
- Wawanesa Life
- Format
- Language
- English
- M7476
Positive Airway Pressure Machine Assessment Form
Documents the medical need for a CPAP or APAP machine so a workplace health plan will cover it.
- Completed by
- Physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- 6253-E
Proof of Death - Physician Statement
Proves a death for an accidental death claim through an association or affinity group plan.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Language
- English
- Form 683
Proof of Death – Physician’s Statement
Confirms a death for a group life claim, signed by the coroner or the last physician in attendance.
- Completed by
- Coroner or last physician in attendance
- Issued by
- Equitable Life
- Format
- Language
- English
-
Proof of Death Physician's Statement
Confirms the death of a plan member so the insurer can pay out a group life claim.
- Completed by
- Attending physician
- Issued by
- The Co-operators
- Format
- Language
- English
- 3503
Royal Bank of Canada LoanProtector HomeProtector Disability Benefit Claim Form
Backs a claim for disability benefits on RBC lines of credit, personal loans and mortgages, and the treating clinician fills out the medical statement built into the form.
- Completed by
- Licensed physician treating the claimant
- Issued by
- RBC Insurance (creditor) / Canada Life
- Format
- Language
- English
- GL2554-STD
Short Term Disability – Attending Physician’s Statement for Mental Health Conditions
Provides the clinical detail for a short term disability claim based on a mental health condition, completed by the treating physician.
- Completed by
- Treating physician
- Issued by
- The Co-operators
- Format
- Fillable PDF
- Language
- English
-
Statement of Claim for Death Benefits (Non Contestable, policy years 3–5, with Attending Physician’s Statement)
Claims death benefits when the death falls in the third to fifth policy year, with a physician's statement as proof of the death.
- Completed by
- Attending physician
- Issued by
- Foresters Financial
- Format
- Fillable PDF
- Language
- English
- ML09E
Supplementary Attending Physician's Statement (APS) – Long Term Disability
Updates an existing SISIP long-term disability claim when the insurer needs more medical information to decide whether benefits should continue.
- Completed by
- Attending physician
- Issued by
- SISIP Financial (Manulife)
- Format
- Fillable PDF
- Language
- English
- FORM-969E
Terminal Illness Claim Form
Claims an early life benefit on a terminal diagnosis, with the attending physician's statement included.
- Completed by
- Attending physician
- Issued by
- Medavie Blue Cross
- Format
- Fillable PDF
- Language
- English
- 4202-E
Waiver of Premium Claim – Physician
Demande de règlement – Exonération de primes – Déclaration du médecin sur l'invalidité
Supports a claim to stop premium payments under a group life policy by documenting that the plan member is disabled, completed by the attending physician.
- Completed by
- Attending physician
- Issued by
- Sun Life
- Format
- Language
- English and French
- 2002000-028A-CL-64
Wheelchair Assessment Form
Gets approval before a plan pays to buy or rent a wheelchair, with the physician giving current medical information.
- Completed by
- Physician (current medical information); supplier completes purchase/rental information
- Issued by
- ClaimSecure
- Format
- Fillable PDF
- Language
- English
Government benefits and tax credits
-
CRA's certificate for the disability tax credit. The patient completes Part A and a medical practitioner certifies the impairment in Part B.
- Completed by
- Patient (Part A); medical practitioner (Part B)
- Issued by
- Canada Revenue Agency
- Format
- Fillable PDF, or digital Part B
- Language
- English and French
-
Certificat médical pour les prestations de maladie de l'assurance-emploi
Service Canada's one-page certificate that a patient can't work for medical reasons, for EI sickness benefits. Section 1 identifies the patient and the medical practitioner certifies the period in Section 2.
- Completed by
- Medical practitioner (Section 2), with the patient's identification in Section 1
- Issued by
- Service Canada
- Format
- Fillable PDF
- Language
- English and French
-
Rapport médical pour prestations d'invalidité du Régime de pensions du Canada
Service Canada's medical report for a CPP disability benefit application. The applicant completes Sections 1 and 2, and a doctor or nurse practitioner completes Sections 3 to 9.
- Completed by
- Applicant (Sections 1 and 2); doctor or nurse practitioner (Sections 3 to 9)
- Issued by
- Service Canada
- Format
- Fillable PDF
- Language
- English and French
- ISP-3505
Certificate of Incapability-OAS/CPP
Certificat d'incapacité - SV/RPC
Certifies that a person cannot handle their own affairs, allowing a trustee, agency or institution to be named to receive and manage their OAS or CPP payments.
- Completed by
- Medical professional: physician, registered nurse, nurse practitioner, psychologist or another listed professional. For seniors, designated non-medical professionals (social worker, lawyer, clergy) may also certify.
- Issued by
- Service Canada
- Format
- Fillable PDF
- Language
- English and French
- ISP-1800
Declaration of Incapacity - Physician's Report
Déclaration d'incapacité - rapport du médecin
States that the patient was unable to decide or say they wanted CPP benefits, with dates, so the application may be treated as filed sooner.
- Completed by
- Physician (Social Security Tribunal decisions show nurse practitioners have also completed it)
- Issued by
- Service Canada
- Format
- Sent for each case
- Language
- English and French
- VAC 1416
Family Physician Assessment
Évaluation du médecin de famille
Gives VAC's health care team a general medical picture of a client from their family physician, including systems review, labs, mental status, therapy, allergies and prognosis.
- Completed by
- Family physician
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- VAC 1753
Follow-up Mental Health Questionnaire for the Veterans Independence Program
Questionnaire de suivi sur la santé mentale pour le Programme pour l'autonomie des anciens combattants
Reassesses whether a veteran still needs Veterans Independence Program help because of a mental health condition, as a follow-up to the initial questionnaire.
- Completed by
- Treating mental health service provider
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- VAC 1752
Initial Mental Health Questionnaire for the Veterans Independence Program
Questionnaire initial sur la santé mentale pour le Programme pour l'autonomie des anciens combattants
Evaluates if mental health problems get in the way of a veteran's housekeeping, grounds work, errands or meals, and recommends help through the Veterans Independence Program.
- Completed by
- Treating mental health service provider: psychologist, psychiatrist, social worker or other qualified health professional
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- INS5216B
Medical Certificate for Employment Insurance Compassionate Care Benefits
Certificat médical pour des prestations de compassion de l'assurance-emploi
Confirms a family member's serious condition carries a high chance of death within 26 weeks, supporting EI compassionate care benefits of up to 26 weeks.
- Completed by
- Medical doctor or nurse practitioner
- Issued by
- Service Canada
- Format
- Fillable PDF
- Language
- English and French
- INS5242B
Medical Certificate for Employment Insurance Family Caregiver Benefits
Certificat médical pour les prestations pour proches aidants de l'assurance-emploi
Confirms a critically ill or injured adult or child needs care, supporting EI family caregiver benefits of 15 weeks at most for an adult or 35 for a child.
- Completed by
- Medical doctor or nurse practitioner
- Issued by
- Service Canada
- Format
- Fillable PDF
- Language
- English and French
- PEN 6249
Medical Questionnaire: Hearing Loss/Tinnitus
Questionnaire médical : Hypoacousie/Acouphène
Records a confirmed hearing loss or tinnitus diagnosis for a veteran's disability benefit assessment.
- Completed by
- Audiologist, physician or NP. Hearing instrument practitioners may be accepted for assessment only, if a qualified professional diagnosed the condition earlier.
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- PEN 6221
Medical Questionnaire: Knee Conditions
Questionnaire médical : affections du genou
Records the diagnosis and assessment of a veteran's knee condition for a disability benefit claim.
- Completed by
- Physician, NP or chiropractor; physiotherapists for assessment or reassessment only
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- PEN 6248
Medical Questionnaire: Psychiatric/Psychological Condition(s)
Questionnaire médical : Affections psychologiques/psychiatriques
Records the diagnosis and severity of a veteran's psychiatric or psychological condition, such as PTSD, for disability benefits; social workers are not accepted.
- Completed by
- Psychiatrist; registered, licensed or associate psychologist; GP; or NP. Candidate psychologists only if co-signed. Psychotherapists and clinical or professional counsellors for assessment only. Social workers are not accepted.
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- PEN 6235
Medical Questionnaire: Thoracolumbar Spine Conditions
Questionnaire médical : Affections de la colonne dorsolombaire
Records the diagnosis and functional assessment for a veteran's lower and mid back condition in a disability benefit claim; physiotherapists may assess but not diagnose.
- Completed by
- Physician, NP or chiropractor; physiotherapists for assessment or reassessment only, not diagnosis
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
-
Medical questionnaires for disability benefits (50 condition-specific forms)
Confirms the diagnosis of each claimed condition and rates its severity against the Table of Disabilities, using one of 50 condition-specific questionnaires for veterans' disability benefits.
- Completed by
- Health professional authorized to diagnose within their scope. GP, specialist or NP for most conditions; physician assistants only in AB, SK, MB, NB, NS and PE. Also chiropractors (musculoskeletal), podiatrists (foot/toe), audiologists (hearing), psychologists and psychiatrists (mental health), dentists (dental), and ophthalmologists or optometrists (vision).
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- ISP-2525
Medical Report - Recurrence of the Same Medical Problem
A short report that the national benefits office requests if a patient's disabling condition returns, connected to Canada Pension Plan disability benefits.
- Completed by
- Treating physician or NP who receives the request
- Issued by
- Service Canada
- Format
- Sent for each case
- Language
- English and French
- VAC 743
Psychological Progress Report
Rapport d'évolution de la psychothérapie
Reports on a veteran's psychological treatment, covering diagnoses, sessions attended and missed, test results, goals met, treatment plan changes and recommended further sessions.
- Completed by
- Treating psychologist or mental health provider registered with Medavie Blue Cross
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- ISP-2509
Reassessment Medical Report
Updates the medical picture when Service Canada reviews whether a person on CPP disability benefits still qualifies; the treating clinician completes it on request.
- Completed by
- Treating health professional who receives the request (typically the physician or NP)
- Issued by
- Service Canada
- Format
- Sent for each case
- Language
- English and French
- ESDC SDE0083
Repayment Assistance Plan for Borrowers with Disabilities – Verification of Disability
Verifies a permanent, persistent or prolonged disability for borrowers applying to the repayment assistance plan for the first time who never received a disability grant.
- Completed by
- Licensed medical practitioner registered where the assessment is done, e.g., physician, nurse practitioner, audiologist, optometrist or psychologist
- Issued by
- ESDC (Canada Student Financial Assistance Program)
- Format
- Fillable PDF
- Language
- English and French
- VAC 1319
Report by Medical Examiner
Rapport du médecin examinateur
Records an examination that VAC orders from a physician, spanning history, physical findings, functional and psychosocial assessment, employability and prognosis.
- Completed by
- Examining physician (medical examiner) at VAC's request
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- VAC 922B
Request for Extension of Treatment
Demande de prolongation du traitement
Asks VAC to fund more treatment sessions than the yearly grid allows, backed by baseline measures, measurable goals and reasons; the veteran signs the certification.
- Completed by
- Treating health professional providing the VAC treatment benefit (the profession varies, e.g., physiotherapy-type services); the Veteran signs the certification
- Issued by
- VAC
- Format
- Fillable PDF
- Language
- English and French
- ESDC SDE0061 MED
Severe Permanent Disability Benefit Medical Report
Rapport médical pour la Disposition applicable aux étudiants ayant une invalidité grave et permanente
Evaluates if a borrower's severe permanent disability rules out substantially gainful work for life, allowing Canada Student Loans and similar federal loans to be cancelled.
- Completed by
- Licensed physician or nurse practitioner
- Issued by
- ESDC (Canada Student Financial Assistance Program)
- Format
- Fillable PDF
- Language
- English and French
- ISP-2530B
Terminal Illness Medical Attestation for a Disability Benefits Application Under the Canada Pension Plan
Attestation médicale de maladie en phase terminale pour une demande de prestations d'invalidité en vertu du Régime de pensions du Canada
Attests that an applicant has a terminal illness so their CPP disability benefit application can be fast-tracked.
- Completed by
- Physician or nurse practitioner
- Issued by
- Service Canada
- Format
- Fillable PDF
- Language
- English and French
Drug coverage
- F13-1109A
Authorization Request – Exception drug – personalized coverage program
Demande d’autorisation d’un médicament d’exception
Requests authorization of an exception drug under iA's personalized individual health insurance coverage.
- Completed by
- Prescribing physician (doctor, resident doctor or dental surgeon)
- Issued by
- iA Financial Group
- Format
- Fillable PDF
- Language
- English and French
- FORM-1171
Blood Glucose Testing Supplies Request (Test Strips and Glucose Monitoring Systems)
Appeals the plan's eligibility limits on test strip quantities, or on continuous and flash glucose monitoring systems, when a patient needs more than the default.
- Completed by
- Physician or pharmacist (plan member/patient completes policy, patient and authorization sections)
- Issued by
- Medavie Blue Cross
- Format
- Fillable PDF
- Language
- English
-
BOTOX - Specialty Prescription Drug - Prior Authorization Request
Requests Medavie Blue Cross coverage of Botox, with separate first-time and renewal sections for spasticity, dystonia, chronic migraine, hyperhidrosis and bladder conditions.
- Completed by
- Physician (patient completes Section 2; a PSP, navigator or pharmacy may complete Section 1)
- Issued by
- Medavie Blue Cross
- Format
- Fillable PDF
- Language
- English
- M6453
Diabetes Step Therapy Drug Exception Form
Requests an exception to the step therapy rules a workplace plan applies to diabetes drugs.
- Completed by
- Prescribing physician or other healthcare provider
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- M7268
Drug Dosage Increase for a previously approved Prior Authorization Drug
Seeks approval of a higher dose for a drug the plan has already authorized through prior authorization.
- Completed by
- Prescribing physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
-
Drug prior authorization
Points to a collection of Desjardins prior authorization forms written for individual drugs on group plans, where the member fills in their own part.
- Completed by
- Attending physician (plan member completes their part)
- Issued by
- Desjardins Insurance
- Format
- Language
- English and French
-
Drug Prior Authorization - Group Benefits
Points to a collection of Manulife prior authorization forms written for individual drugs on group plans, where the member fills in their own part.
- Completed by
- Prescribing physician (plan member completes their part)
- Issued by
- Manulife
- Format
- Language
- English
- M6453
Drug Prior Authorization Form - Adalimumab
Supplies the details Canada Life requires to assess a workplace plan claim for adalimumab, either Humira or a listed biosimilar.
- Completed by
- Prescribing physician (plan member completes the Patient Information page and signs the consent)
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- M6453
Drug Prior Authorization Form - Dupixent (dupilumab)
Supplies the details Canada Life requires to assess a workplace plan claim for Dupixent in asthma, skin, sinus, COPD and esophageal conditions.
- Completed by
- Prescribing physician (plan member completes the Patient Information page and signs the consent)
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- M6453
Drug Prior Authorization Form - Migraine: Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab), Qulipta (atogepant), Vyepti (eptinezumab)
Supplies the details Canada Life requires to assess a claim for Qulipta, Vyepti, Aimovig, Ajovy or Emgality to prevent migraine, or episodic cluster headache for Emgality.
- Completed by
- Prescribing physician (plan member completes the Patient Information page and signs the consent)
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- M6453
Drug Prior Authorization Form - semaglutide (Ozempic and generics)
Supplies the details Canada Life requires to assess a claim for semaglutide in type 2 diabetes, diabetic kidney disease or cardiovascular risk reduction.
- Completed by
- Prescribing physician (plan member completes the Patient Information page and signs the consent)
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- M6453
Drug Prior Authorization Form - Wegovy (semaglutide)
Supplies the details Canada Life requires to assess a claim for Wegovy used for weight management, MASH or preventing a myocardial infarction.
- Completed by
- Prescribing physician (plan member completes the Patient Information page and signs the consent)
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- M6453
Drug Prior Authorization Form – Medical Cannabis
Requests prior authorization so a workplace drug plan will pay for medical cannabis.
- Completed by
- Prescribing physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
-
DUPIXENT - Specialty Prescription Drug - Prior Authorization Request
Requests Medavie Blue Cross coverage of Dupixent for atopic dermatitis, asthma, sinus disease, eosinophilic esophagitis, prurigo nodularis, COPD or urticaria, covering both first requests and renewals.
- Completed by
- Physician (patient completes Section 2; a PSP, navigator or pharmacy may complete Section 1)
- Issued by
- Medavie Blue Cross
- Format
- Fillable PDF
- Language
- English
-
End-of-life care formulary application form (NIHB)
Gets a client receiving palliative-stage care onto NIHB's special drug list for the end of life, so the prescriber can use those medications.
- Completed by
- Prescriber
- Issued by
- Indigenous Services Canada (NIHB)
- Format
- Sent for each case
- Language
- English and French
-
Exception Drugs Request Form (NIHB)
Asks NIHB to cover a drug missing from its formulary for an Inuit or First Nations client, and explains why the exception is clinically justified.
- Completed by
- Licensed prescriber
- Issued by
- Indigenous Services Canada (NIHB)
- Format
- Sent for each case
- Language
- English and French
- GL5197E
Group Benefits Drug Prior Authorization - Dupixent (Dupilumab)
Autorisation préalable de médicaments - Assurance collective - Dupixent (dupilumab)
Supplies the medical details Manulife needs to rule on Dupixent coverage for atopic dermatitis, nasal polyps with chronic sinusitis, or asthma.
- Completed by
- Prescribing physician (plan member completes Sections 1 to 3 and signs Section 7)
- Issued by
- Manulife
- Format
- Fillable PDF
- Language
- English and French
- GL5197E
Group Benefits Drug Prior Authorization - Mounjaro (tirzepatide)
Autorisation préalable de médicaments - Assurance collective - Mounjaro (tirzépatide)
Supplies the medical details Manulife needs to rule on Mounjaro coverage for glycemic control in adults with type 2 diabetes.
- Completed by
- Prescribing physician (plan member completes Sections 1 to 3 and signs Section 7)
- Issued by
- Manulife
- Format
- Fillable PDF
- Language
- English and French
- GL5197E
Group Benefits Drug Prior Authorization - Ozempic (semaglutide)
Autorisation préalable de médicaments - Assurance collective - Ozempic (sémaglutide)
Supplies the medical details Manulife needs to rule on Ozempic coverage, since the drug sits on the plan's prior authorization list.
- Completed by
- Prescribing physician (plan member completes Sections 1 to 3 and signs Section 7)
- Issued by
- Manulife
- Format
- Fillable PDF
- Language
- English and French
- GL5197E
Group Benefits Drug Prior Authorization - Rinvoq (upadacitinib)
Autorisation préalable de médicaments - Assurance collective - Rinvoq (upadacitinib)
Supplies the medical details Manulife needs to rule on Rinvoq coverage, spanning giant cell arteritis plus its rheumatology, dermatology and gastroenterology uses.
- Completed by
- Prescribing physician (plan member completes Sections 1 to 3 and signs Section 7)
- Issued by
- Manulife
- Format
- Fillable PDF
- Language
- English and French
- GL5197E
Group Benefits Drug Prior Authorization - Wegovy (semaglutide)
Autorisation préalable de médicaments - Assurance collective - Wegovy (sémaglutide)
Supplies the medical details Manulife needs to rule on Wegovy coverage for chronic weight management or reducing the risk of myocardial infarction.
- Completed by
- Prescribing physician (plan member completes Sections 1 to 3 and signs Section 7)
- Issued by
- Manulife
- Format
- Fillable PDF
- Language
- English and French
- GL5197E
Group Benefits Drug Prior Authorization - Zepbound (tirzepatide)
Autorisation préalable de médicaments - Assurance collective - Zepbound (tirzépatide)
Supplies the medical details Manulife needs to rule on Zepbound coverage for chronic weight management, or for obesity alongside obstructive sleep apnea.
- Completed by
- Prescribing physician (plan member completes Sections 1 to 3 and signs Section 7)
- Issued by
- Manulife
- Format
- Fillable PDF
- Language
- English and French
-
Limited Use Benefit Request Form (NIHB)
Obtains prior approval for an NIHB drug that is covered only when the client meets specific criteria set by the program.
- Completed by
- Licensed prescriber
- Issued by
- Indigenous Services Canada (NIHB)
- Format
- Sent for each case
- Language
- English and French
-
Liraglutide (Victoza) / Semaglutide (Ozempic / Rybelsus) Special Authorization Request Form
Asks GreenShield to cover Ozempic, Victoza or Rybelsus for adults whose type 2 diabetes stays uncontrolled despite diet, exercise and the highest metformin dose they tolerate.
- Completed by
- Prescriber (patient completes Section 1)
- Issued by
- GreenShield
- Format
- Language
- English
-
Prescription Drug Special Authorization Request Form - Anti-Obesity Agents
Formulaire de demande d'autorisation spéciale - Agents anti-obésité
Requests plan coverage of Contrave or Saxenda for chronic weight management, applying BMI criteria at the start and a 5% weight-loss test at renewal.
- Completed by
- Prescriber (patient completes Section 1)
- Issued by
- GreenShield
- Format
- Fillable PDF
- Language
- English and French
-
Prescription Drug Special Authorization Request Form - Onabotulinumtoxin A (Botox) for Migraine Prevention
Formulaire de demande d'autorisation spéciale - Onabotulinumtoxin A (Botox) - Prévention de la migraine
Requests plan coverage of Botox to prevent chronic migraine in adults; only a neurologist, pain specialist or headache specialist can prescribe, and renewal needs a 40% drop in headache days.
- Completed by
- Prescriber, who must be a neurologist, pain specialist or headache specialist (patient completes Section 1)
- Issued by
- GreenShield
- Format
- Fillable PDF
- Language
- English and French
-
Prior Authorization Drug List and Forms
Points to a collection of Sun Life prior authorization forms written for individual drugs on group plans, where the member fills in their own part.
- Completed by
- Prescribing physician (plan member completes their part)
- Issued by
- Sun Life
- Format
- Language
- English and French
-
Prior authorization drugs
Lets you search Beneva's group exception drug forms by drug name or medical condition to find the right prior authorization request.
- Completed by
- Prescribing physician (plan member completes their part)
- Issued by
- Beneva
- Format
- Language
- English and French
- M6453
Prior authorization forms
Points to a collection of Canada Life prior authorization forms written for individual drugs on workplace plans, where the member fills in their own part.
- Completed by
- Prescribing physician (plan member completes their part)
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
-
Prior authorization forms
Points to a collection of Medavie prior authorization forms written for individual drugs on group plans, where the member fills in their own part.
- Completed by
- Prescribing physician (plan member completes their part)
- Issued by
- Medavie Blue Cross
- Format
- Language
- English
-
Prior Authorization Program
Lets you look up the prior authorization form for a drug across the plan sponsors and insurers whose benefits Express Scripts Canada manages.
- Completed by
- Prescribing physician (Part B); patient completes Part A
- Issued by
- Express Scripts Canada
- Format
- Language
- English and French
-
Prior Authorization Program (Express Scripts Canada) – Empire Life
Reaches the prior authorization forms for individual drugs on Empire Life group plans, found through the Express Scripts Canada form search.
- Completed by
- Prescribing physician (Part B); patient completes Part A
- Issued by
- Empire Life
- Format
- Language
- English and French
-
Prior Authorization Request - AJOVY (fremanezumab)
Demande d'autorisation préalable - AJOVY (frémanezumab)
Requests Sun Life group coverage of Ajovy to prevent migraine, with different start and renewal criteria in adults and in episodic migraine for ages 6 to 17.
- Completed by
- Prescribing physician (plan member completes Part A)
- Issued by
- Sun Life
- Format
- Fillable PDF
- Language
- English and French
-
Prior Authorization Request - BOTOX (onabotulinumtoxinA)
Demande d'autorisation préalable - BOTOX (onabotulinumtoxinA)
Requests Sun Life group coverage of Botox, setting out the conditions covered: blepharospasm, cervical dystonia, spasticity, strabismus, bladder conditions, chronic migraine and underarm hyperhidrosis.
- Completed by
- Prescribing physician (plan member completes Part A)
- Issued by
- Sun Life
- Format
- Fillable PDF
- Language
- English and French
-
Prior Authorization Request - DUPIXENT (dupilumab)
Demande d'autorisation préalable - DUPIXENT (dupilumab)
Requests Sun Life group coverage of Dupixent for atopic dermatitis, asthma, nasal polyps, eosinophilic esophagitis or prurigo nodularis, with distinct first-request and renewal criteria.
- Completed by
- Prescribing physician (plan member completes Part A)
- Issued by
- Sun Life
- Format
- Fillable PDF
- Language
- English and French
-
Prior Authorization Request - HUMIRA, ABRILADA, AMGEVITA, HADLIMA, HULIO, HYRIMOZ, IDACIO, SIMLANDI, YUFLYMA (adalimumab)
Demande d'autorisation préalable - HUMIRA, ABRILADA, AMGEVITA, HADLIMA, HULIO, HYRIMOZ, IDACIO, SIMLANDI, YUFLYMA (adalimumab)
Requests group plan coverage of adalimumab, either Humira or a biosimilar, across 10 indications, with an added intolerance criterion when Humira itself is requested.
- Completed by
- Prescribing physician (plan member completes Part A)
- Issued by
- Sun Life
- Format
- Fillable PDF
- Language
- English and French
-
Prior Authorization Request - SKYRIZI (risankizumab)
Demande d'autorisation préalable - SKYRIZI (risankizumab)
Requests Sun Life group coverage of Skyrizi for adults with plaque psoriasis, psoriatic arthritis, ulcerative colitis or Crohn's.
- Completed by
- Prescribing physician (plan member completes Part A)
- Issued by
- Sun Life
- Format
- Fillable PDF
- Language
- English and French
-
Prior Authorization Request - STELARA, FINLIUS, JAMTEKI, STEQEYMA, WEZLANA, YESINTEK (ustekinumab)
Requests Sun Life group coverage of Stelara or a ustekinumab biosimilar for Crohn's, ulcerative colitis, plaque psoriasis or psoriatic arthritis, with an extra intolerance criterion for Stelara itself.
- Completed by
- Prescribing physician (plan member completes Part A)
- Issued by
- Sun Life
- Format
- Fillable PDF
- Language
- English and French
-
Prior Authorization Request - WEGOVY (semaglutide)
Demande d'autorisation préalable - WEGOVY (sémaglutide)
Requests Sun Life group coverage of Wegovy for long-term weight management, with separate start and renewal criteria for adults and for patients aged 12 to 18.
- Completed by
- Prescribing physician (plan member completes Part A)
- Issued by
- Sun Life
- Format
- Fillable PDF
- Language
- English and French
- 10108E
Prior authorization request – General form
Demande d'autorisation générale pour un médicament
Covers any drug prior authorization request to Desjardins when the drug in question has no form of its own.
- Completed by
- Attending physician
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
- GL4445
Request for Approval of Brand-Name Drug – Group Benefits
Asks for approval of a brand-name drug because the lowest-cost interchangeable alternative is not tolerated or does not work.
- Completed by
- Prescribing physician
- Issued by
- Manulife
- Format
- Language
- English
- M6453
Request for Blood Glucose Test Strips
Requests more blood glucose test strips than the provincially indicated amount allows within a 365-day period.
- Completed by
- Prescribing physician or other healthcare provider
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- M7088
Request for Brand Name Drug Coverage
Asks the plan to cover a brand-name drug where the lower-cost alternative would normally apply.
- Completed by
- Prescribing physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- F54-835A
Request for brand name drug exception
Formulaire d'exception pour un médicament d'origine
Asks iA to cover a brand-name drug when the generic would normally be the covered choice.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Language
- English and French
- GRP-5008-EN
Request for Drug Substitution
Asks approval to substitute one drug for another under an Empire Life plan's extended health benefit terms.
- Completed by
- Prescribing healthcare professional
- Issued by
- Empire Life
- Format
- Fillable PDF
- Language
- English
- M6453
Request for Originator Biologic Drug Coverage
Asks the plan to cover an originator biologic where a biosimilar would normally be required.
- Completed by
- Prescribing physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- F54-859A
Request for prior authorization – Drugs
Formulaire d’autorisation préalable – Médicaments
Serves as the general prior authorization request for iA group drug plans, with the insurer's drug-specific variants listed alongside it.
- Completed by
- Prescribing physician
- Issued by
- iA Financial Group
- Format
- Language
- English and French
- F54-1025A
Request for reference biologic drug exception
Formulaire d’exception pour un médicament biologique
Asks iA to cover the reference biologic when a biosimilar would normally be the covered choice.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Language
- English and French
- 12126E
Request for reimbursement of brand-name medications
Demande de remboursement pour un médicament de marque
Asks Desjardins to reimburse the brand-name version of a drug rather than the generic.
- Completed by
- Attending physician
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
- 21084E
Request for reimbursement of reference biologic drugs
Demande de remboursement pour un médicament biologique de référence
Asks Desjardins to reimburse the originator biologic in place of a biosimilar for a given patient.
- Completed by
- Attending physician
- Issued by
- Desjardins Insurance
- Format
- Fillable PDF
- Language
- English and French
- Form A
Special Access Program (drugs) – Form A: Patient-specific request
Seeks urgent access to a drug that isn't marketed in Canada for one named patient whose condition is serious or threatens their life.
- Completed by
- Treating practitioner
- Issued by
- Health Canada
- Format
- Fillable PDF
- Language
- English and French
- Form B
Special Access Program (drugs) – Form B: Future use request (patient identity unknown)
Requests a non-marketed drug in advance for possible emergency use when no patient is identified yet, and states why it is needed ahead of time.
- Completed by
- Practitioner (e.g., on behalf of a hospital or clinic)
- Issued by
- Health Canada
- Format
- Fillable PDF
- Language
- English and French
- Form C
Special Access Program (drugs) – Form C: Follow-up form
Reports back to Health Canada on how a drug obtained through the Special Access Program worked, including any adverse reactions, and is mandatory after use.
- Completed by
- Practitioner who received the drug
- Issued by
- Health Canada
- Format
- Fillable PDF
- Language
- English and French
-
Special Authorization Request – Standard Form
Serves as the standard special authorization request for drug coverage under plans that ClaimSecure administers.
- Completed by
- Physician
- Issued by
- ClaimSecure
- Format
- Fillable PDF
- Language
- English
Driving and licensing
- 26-0862A
Civil Aviation - Fit Certification
Is issued by an aviation medical examiner after a telemedicine renewal of a medical certificate, and the holder keeps it with that certificate or booklet.
- Completed by
- Civil Aviation Medical Examiner (CAME)
- Issued by
- Transport Canada
- Language
- English and French
- 26-0010
Civil Aviation Medical Examination Report
Rapport d'examen médical de l'aviation civile
Records the exam a designated aviation medical examiner performs, which feeds certificates for pilots, controllers and other licence holders.
- Completed by
- Civil Aviation Medical Examiner (CAME) designated by Transport Canada only
- Issued by
- Transport Canada
- Format
- Fillable PDF
- Language
- English and French
- 26-0011
Civil Aviation Medicine Medical Condition Reporting Form
Formulaire de déclaration de l'état de santé de la médecine aéronautique civile
Lets any physician or optometrist alert the regulator to a patient's condition that affects flight safety, for example in a pilot.
- Completed by
- Physician or optometrist (any, not only CAMEs)
- Issued by
- Transport Canada
- Format
- Fillable PDF
- Language
- English and French
- 26-0297
Medical Declaration for Licences and Permits Requiring a Category 4 Medical Standard
Déclaration médicale pour les licences et les permis nécessitant une catégorie 4 norme médicale
Lets an applicant self-declare medical fitness for permits needing a Category 4 certificate, with a family physician countersigning Part B for student and recreational pilot permits.
- Completed by
- Applicant; family physician countersigns Part B where required (student pilot permit for aeroplanes, recreational pilot permit)
- Issued by
- Transport Canada
- Format
- Language
- English and French
- 82-0808
National Marine Pilotage Medical Report
Reports on a marine pilot's medical fitness against the national marine pilotage medical standard.
- Completed by
- Examining physician (likely a designated Marine Medical Examiner)
- Issued by
- Transport Canada
- Format
- Sent for each case
- Language
- Bilingual
- 82-0662P
Provisional Marine Medical Certificate
Gives a seafarer a paper provisional marine medical certificate while the marine medical examination report is under review.
- Completed by
- Marine Medical Examiner (designated)
- Issued by
- Transport Canada
- Format
- Sent for each case
- Language
- English and French
Parking, transit and travel
-
Access 2 Card Application Form
A clinician confirms the applicant has a disability and needs someone along for support, which lets that person enter participating venues at no charge or a reduced price.
- Completed by
- Accepted health care professional (e.g., physician, nurse, psychologist, OT, audiologist, recreational therapist; full list on form) or Executive Director of a recognized service provider; must not be related to the applicant
- Issued by
- Easter Seals Canada
- Format
- Fillable PDF
- Language
- English
-
Air Travel Requirements Assessment Form
Assesses whether a passenger is fit to fly and documents needs for onboard oxygen, medical equipment, a support person or extra seating on major Canadian airlines.
- Completed by
- Physician, nurse practitioner or physician assistant
- Issued by
- National Airlines Council of Canada common form (Air Canada, Air Transat, WestJet, Jazz); also used by Flair
- Format
- Fillable PDF
- Language
- English
- Form B
Request for Additional Seating for Attendant for Reasons of Disability
Backs a request for a personal attendant to sit free on a domestic Porter flight when the passenger needs care or safety help beyond what onboard crew give.
- Completed by
- Physician, NP or physician assistant
- Issued by
- Porter Airlines
- Format
- Fillable PDF
- Language
- English
- Form A
Request for Additional Seating for Self for Reasons of Disability
Supports a passenger's request for an extra or specific seat at no charge on a domestic flight because of a disability such as an immobilized leg.
- Completed by
- Physician, NP or physician assistant (a physiotherapist may sign a renewal if no comorbidities and fitness to fly unchanged in two years)
- Issued by
- Porter Airlines
- Format
- Fillable PDF
- Language
- English
- Form C
Request for Portable Oxygen Concentrator (POC) Use in Flight
Lets a physician authorize a patient to use an approved portable oxygen concentrator during a flight.
- Completed by
- Physician
- Issued by
- Porter Airlines
- Format
- Fillable PDF
- Language
- English
-
Request to travel with a support person
The clinician states that the patient has a disability and has to be accompanied by a companion, so the companion pays no separate fare on VIA Rail.
- Completed by
- Attending physician or authorized health care professional (form lists psychiatrist, psychologist or nurse practitioner; VIA's page also lists audiologist and optometrist)
- Issued by
- VIA Rail Canada
- Format
- Fillable PDF
- Language
- English
-
Request to travel with an emotional support dog
Confirms that a patient needs an emotional support dog while travelling, so the animal can ride with them on the train.
- Completed by
- Treating healthcare professional: psychiatrist, psychologist or attending physician
- Issued by
- VIA Rail Canada
- Format
- Fillable PDF
- Language
- English
Health programs
-
Application Form for Special Access Medical Devices
Formulaire de demande d'accès spécial aux instruments médicaux
Applies on a patient's behalf for a medical device not licensed in Canada, through Health Canada's special access route for devices.
- Completed by
- Health care professional (must sign)
- Issued by
- Health Canada
- Format
- Fillable PDF
- Language
- English and French
-
Medical document authorizing the use of cannabis for medical purposes
Document médical autorisant la consommation de cannabis à des fins médicales
Supports a patient's medical use of cannabis so they can purchase from a seller holding a federal licence or register to grow their own or have it grown.
- Completed by
- Health care practitioner (as defined in the Cannabis Regulations)
- Issued by
- Health Canada
- Format
- Language
- English and French
-
Mental Health Counselling Prior Approval and Claim Form (NIHB)
Handles NIHB mental health counselling billing steps for enrolled providers: prior approval, requests for extra hours, approval after the fact, and claims.
- Completed by
- Enrolled NIHB mental health counselling provider (e.g., psychologist, counsellor)
- Issued by
- Indigenous Services Canada (NIHB)
- Language
- English and French
-
NIHB Medical Supplies and Equipment (MS&E) benefit-specific prior approval forms
Autorisation préalable - [type de prestation] (SSNA, équipement médical et fournitures médicales)
Secures NIHB prior approval before a provider supplies items like mobility aids, oxygen, orthotics, prosthetics or CPAP, sent with the prescription and any required assessments.
- Completed by
- Enrolled MS&E provider (Section G signature with Express Scripts Canada provider number; for oxygen an RRT, RN trained in respiratory care, or RPN/LPN within scope). Prescriber or recommender is named in Section D and supplies a signed prescription; mobility requests also need an OT or PT assessment
- Issued by
- Indigenous Services Canada (NIHB)
- Format
- Fillable PDF
- Language
- English and French
Other forms
- IMM 5728
Confirmation of Counselling after HIV Positive Test or Status Disclosure
Confirms a panel physician counselled an immigration medical client after a positive HIV test or a disclosure of positive status.
- Completed by
- Panel physician
- Issued by
- IRCC
- Format
- Online portal or EMR
- Language
- English and French
- CIT 0547
Medical Opinion Form for Citizenship Waivers
Formulaire d'avis médical : dispenses relatives à la citoyenneté
Backs a citizenship applicant who asks to waive the test requirements or the oath due to a severe, prolonged medical condition.
- Completed by
- Attending medical practitioner: GP or family physician (CCFP), other physician specialist, psychologist or nurse practitioner
- Issued by
- IRCC
- Format
- Fillable PDF
- Language
- English and French
- IMM 1017
Medical Report – Client Biodata and Summary
Rapport médical – Sommaire et données biométriques du client
Records an immigration medical examination for any immigration category, with the client's biodata, the overall grading of the exam and the signed declaration of the panel physician.
- Completed by
- IRCC-designated panel physician only
- Issued by
- IRCC
- Format
- Online portal or EMR
- Language
- English and French
- IMM 5419
Medical Report (paper-based immigration medical examination)
Rapport médical
Serves as the paper immigration medical examination report, with laboratory and chest x-ray requisitions, for use only where eMedical is unavailable.
- Completed by
- Panel physician; panel radiologist (chest x-ray section)
- Issued by
- IRCC
- Format
- Sent for each case
- Language
- English and French
- IMM 5733
Pregnant Client – X-Ray Deferred
Cliente enceinte – Radiographie différée
Records that a pregnant immigration medical client decided to postpone the chest x-ray, with eMedical producing a deferral letter and instructions.
- Completed by
- Panel physician
- Issued by
- IRCC
- Format
- Online portal or EMR
- Language
- English and French
- IMM 5544
Resettlement Needs Assessment
Formulaire pour l'évaluation des besoins de réétablissement
Lets a panel physician record what refugee applicants examined overseas need medically and for resettlement.
- Completed by
- Panel physician
- Issued by
- IRCC
- Format
- Online portal or EMR
- Language
- English and French
British Columbia
Lab and imaging requisitions
- DCBM_100_100F
Bacteriology and Mycology Requisition
The BCCDC Public Health Laboratory requisition for bacterial and fungal testing, with a second page for isolates sent for identification. The ordering practitioner or referring lab completes it.
- Completed by
- Ordering practitioner or referring laboratory
- Issued by
- BCCDC Public Health Laboratory (PHSA)
- Format
- Fillable PDF
- Language
- English
-
BC Cancer's requisition for HPV and cervical cytology testing at the Cervical Cancer Screening Laboratory. The sample provider completes it.
- Completed by
- Sample provider (physician, nurse practitioner, RN, ND or locum)
- Issued by
- BC Cancer, Cervical Cancer Screening Laboratory
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' private-pay requisition for its hereditary cancer gene panel with genetic counselling, in BC and Ontario. The ordering provider completes the order and the patient signs the genetic testing consent.
- Completed by
- Ordering healthcare provider; patient or substitute decision maker (genetic testing consent)
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' private-pay requisition for Alzheimer's blood biomarkers in British Columbia, including p-tau217, the amyloid 42/40 ratio and ApoE. The ordering practitioner completes and signs it.
- Completed by
- Authorized ordering healthcare practitioner
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' private-pay requisition for the Klinrisk chronic kidney disease risk score in British Columbia. The ordering physician completes and signs it.
- Completed by
- Ordering physician
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' own outpatient lab requisition for British Columbia. The ordering practitioner completes and signs it, and the patient brings it to a LifeLabs Patient Service Centre.
- Completed by
- Ordering practitioner
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
- PHRQ_MTB_0001F
Mycobacteriology / TB Requisition
The BCCDC Public Health Laboratory requisition for AFB smear, mycobacterial culture and TB nucleic acid testing. The ordering practitioner or referring lab completes it.
- Completed by
- Ordering practitioner or referring laboratory
- Issued by
- BCCDC Public Health Laboratory (PHSA)
- Format
- Fillable PDF
- Language
- English
- PHRQ_PAR_0001F
Parasitology Requisition
The BCCDC Public Health Laboratory requisition for ova and parasites, pinworm, blood and tissue parasites, malaria and ectoparasite identification. The ordering practitioner completes and signs it.
- Completed by
- Ordering practitioner
- Issued by
- BCCDC Public Health Laboratory (PHSA)
- Format
- Fillable PDF
- Language
- English
- PHRQ_HVS_0001F
Serology Screening Requisition
The BCCDC Public Health Laboratory requisition for prenatal screening, syphilis, HIV, hepatitis panels and other immunity or acute serology. The ordering practitioner completes and signs it.
- Completed by
- Ordering practitioner
- Issued by
- BCCDC Public Health Laboratory (PHSA)
- Format
- Fillable PDF
- Language
- English
-
BC's standard requisition for bone mineral densitometry. The requesting practitioner records the fracture risk and whether the exam is insured, an early follow-up or patient pay.
- Completed by
- Requesting practitioner (family physician or nurse practitioner)
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
-
BC's standard requisition for community laboratory tests. The ordering practitioner completes and signs it, and the collector fills in the collection details.
- Completed by
- Ordering practitioner; the collector completes the collection fields
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
- PHRQ_VIR_0001F
Virology Requisition
The BCCDC Public Health Laboratory requisition for respiratory, skin and mucosal, encephalitis, gastrointestinal and measles, mumps and rubella virus testing. The ordering practitioner completes and signs it.
- Completed by
- Ordering practitioner
- Issued by
- BCCDC Public Health Laboratory (PHSA)
- Format
- Fillable PDF
- Language
- English
- PHRQ_ZEP_0001F
Zoonotic Diseases and Emerging Pathogens Requisition
The BCCDC Public Health Laboratory requisition for antibody, antigen and PCR testing for zoonotic viruses, bacteria, fungi, parasites, syphilis and diphtheria or tetanus antitoxin. The ordering practitioner completes and signs it.
- Completed by
- Ordering practitioner
- Issued by
- BCCDC Public Health Laboratory (PHSA)
- Format
- Fillable PDF
- Language
- English
- HLTH 1935
Standard Out-Patient Laboratory Requisition for Maternity Care
Orders prenatal bloodwork and other lab tests, grouped by gestational age following Perinatal Services BC guidance, with space for additional tests as clinically needed.
- Completed by
- Requesting practitioner providing maternity care; collector completes collection fields
- Issued by
- BC Ministry of Health (standard outpatient requisitions)
- Format
- Language
- English
Referrals
-
The letter a BC emergency department completes after a blood or body fluid exposure. It tells the exposed person's follow-up physician what was given and which tests and doses are still needed.
- Completed by
- Emergency department physician; acted on by the follow-up physician
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
-
BC Cancer's referral to its Pain and Symptom Management/Palliative Care team at any regional centre. The referring clinician completes it.
- Completed by
- Referring physician or nurse practitioner
- Issued by
- BC Cancer
- Format
- Fillable PDF
- Language
- English
-
BC's optional standard referral to a sleep disorder physician or accredited polysomnography facility. The referring practitioner completes and signs it.
- Completed by
- Referring practitioner
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
Workers' compensation
- Form 8/11
Physician's Report
WorkSafeBC's combined physician report: Form 8 is the first report on a work injury claim and Form 11 the progress report. The treating physician completes it.
- Completed by
- Treating physician
- Issued by
- WorkSafeBC
- Format
- Fillable PDF, or electronic through Teleplan
- Language
- English
- 51D4
Audiological Diagnostic Assessment (Form 51D4)
Records the findings of a full audiological assessment to back a hearing claim made to WorkSafeBC.
- Completed by
- Registered audiologist (WorkSafeBC hearing provider network)
- Issued by
- WorkSafeBC
- Format
- Language
- English
- 83D6
Authorization Request for Surgery (Form 83D6)
Asks WorkSafeBC to authorize surgery on a claim before the specialist operates.
- Completed by
- Surgeon / specialist physician
- Issued by
- WorkSafeBC
- Language
- English
- 83D667
Chiropractic Treatment Report (Form 83D667)
Supports a chiropractor's request to extend musculoskeletal treatment, and covers intake and extension requests for concussion or vestibular care on a workers' compensation claim.
- Completed by
- Chiropractor
- Issued by
- WorkSafeBC
- Language
- English
- Form 8C/11C
Chiropractor's Report (Form 8C/11C)
Reports a worker's injury after the chiropractor's first assessment, then closes out the claim with a discharge report when care ends.
- Completed by
- Chiropractor
- Issued by
- WorkSafeBC
- Language
- English
- Form 11RC
Chiropractor's X-ray Report (Form 11RC)
Reports what a chiropractor found on X-rays, when films were taken and bear on the worker's compensable injury.
- Completed by
- Chiropractor
- Issued by
- WorkSafeBC
- Language
- English
- 83D682
Comprehensive Mental Health Program Report
Lets a contracted registered psychologist, clinical counsellor or clinical social worker report on a worker's treatment within the Comprehensive Mental Health Program.
- Completed by
- Contracted registered psychologist, clinical counsellor or clinical social worker
- Issued by
- WorkSafeBC
- Language
- English
- 83D599
Concussion and Vestibular Physiotherapy (CVPT) Assessment Report
Reports the initial assessment of a worker by a contracted concussion and vestibular physiotherapist on a WorkSafeBC claim.
- Completed by
- Physiotherapist (WorkSafeBC-contracted CVPT provider)
- Issued by
- WorkSafeBC
- Language
- English
- 83D601
Concussion and Vestibular Physiotherapy (CVPT) Discharge Report
Reports a worker's discharge from concussion and vestibular physiotherapy, completed by the contracted physiotherapist on a WorkSafeBC claim.
- Completed by
- Physiotherapist (WorkSafeBC-contracted CVPT provider)
- Issued by
- WorkSafeBC
- Language
- English
- 83D600
Concussion and Vestibular Physiotherapy (CVPT) Extension Request
Asks WorkSafeBC to extend a worker's concussion and vestibular physiotherapy treatment beyond the approved sessions.
- Completed by
- Physiotherapist (WorkSafeBC-contracted CVPT provider)
- Issued by
- WorkSafeBC
- Language
- English
-
Contracted rehabilitation program report forms
A set of report templates for programs under contract with WorkSafeBC, such as psychology, occupational therapy, functional capacity evaluation, hand therapy, concussion, pain and hearing.
- Completed by
- Contracted psychologists, clinical counsellors, social workers, OTs, physiotherapists, kinesiologists, audiologists and program physicians
- Issued by
- WorkSafeBC
- Format
- Word document
- Language
- English
- Form 382
Dentist's Report of Injury (Form 382)
Reports a work-related injury to the teeth or mouth once the dentist or denturist has completed the first exam.
- Completed by
- Dentist or denturist
- Issued by
- WorkSafeBC
- Format
- Language
- English
- 83D516
Extension of Massage Therapy Treatment Request (Form 83D516)
Asks to continue a worker's massage therapy beyond the initial eight weeks.
- Completed by
- Registered massage therapist
- Issued by
- WorkSafeBC
- Format
- Language
- English
- 83D76
Functional Capacity Evaluation (FCE) or Cognitive Functional Capacity Evaluation (Cognitive FCE) Report
A contracted evaluator reports the findings from a functional capacity evaluation, which can be physical or cognitive.
- Completed by
- Contracted FCE provider (the page does not name the discipline; typically OT or physiotherapist)
- Issued by
- WorkSafeBC
- Format
- Word document
- Language
- English
- 83D51
Generic Report - Medical and Health Care (Form 83D51)
Answers WorkSafeBC's request for information from a provider who has no dedicated report form, such as an acupuncturist, optometrist or podiatrist.
- Completed by
- Acupuncturists, optometrists, podiatrists, speech-language pathologists and other providers without a dedicated form
- Issued by
- WorkSafeBC
- Format
- Word document
- Language
- English
- 83D202
Graduated Return-to-Work (GRTW) Plan
The clinician who runs the contracted rehabilitation program writes down a worker's plan for a gradual return to work.
- Completed by
- Contracted program clinician (e.g. OT, physiotherapist, kinesiologist or mental health provider)
- Issued by
- WorkSafeBC
- Format
- Word document
- Language
- English
- 83D48
Massage Therapy Treatment Report (Form 83D48)
Reports a massage therapist's findings after the initial assessment, and again whenever WorkSafeBC asks for one.
- Completed by
- Registered massage therapist
- Issued by
- WorkSafeBC
- Format
- Word document
- Language
- English
- Form 8N
Naturopathic First Report (Form 8N)
Opens a claim file with a naturopathic physician's first account of a worker treated after a compensable injury, illness or mental disorder.
- Completed by
- Naturopathic physician
- Issued by
- WorkSafeBC
- Language
- English
- Form 11N
Naturopathic Physician's Progress Report (Form 11N)
Updates the claim on a worker's progress with a naturopathic physician, and is the form used to ask for treatment beyond eight weeks.
- Completed by
- Naturopathic physician
- Issued by
- WorkSafeBC
- Language
- English
- Form 8NP/11NP
Nurse Practitioner's Report (Form 8NP/11NP)
Covers both the first report and the later progress report a nurse practitioner sends on a worker's claim.
- Completed by
- Nurse practitioner
- Issued by
- WorkSafeBC
- Format
- Fillable PDF
- Language
- English
- 83D487
Occupational Therapy Services Progress Report
Reports a contracted occupational therapist's progress with a worker under WorkSafeBC's occupational therapy services.
- Completed by
- Contracted occupational therapist
- Issued by
- WorkSafeBC
- Format
- Word document
- Language
- English
- 83D346
Physiotherapy Hospital Report (83D346)
Reports a hospital physiotherapy department's treatment of an injured worker on a WorkSafeBC claim.
- Completed by
- Hospital physiotherapist
- Issued by
- WorkSafeBC
- Format
- Word document
- Language
- English
- 83D665
Physiotherapy Treatment Report (Form 83D665)
Reports a worker's progress and requests extended treatment from a contracted musculoskeletal physiotherapist.
- Completed by
- Physiotherapist (WorkSafeBC-contracted MSK provider)
- Issued by
- WorkSafeBC
- Language
- English
- 83D555
Physiotherapy Treatment/Post-Surgical Initial Report (Form 83D555)
A contracted musculoskeletal physiotherapist reports their first assessment of a worker, using either the standard version or the one for after surgery.
- Completed by
- Physiotherapist (WorkSafeBC-contracted MSK provider)
- Issued by
- WorkSafeBC
- Language
- English
- Form 8/11 Addendum
Practitioners Report/Additional Information (Form 8/11 Addendum)
Gives a physician or chiropractor extra room for clinical details that will not fit on the standard first or progress report.
- Completed by
- Physician or chiropractor
- Issued by
- WorkSafeBC
- Format
- Fillable PDF
- Language
- English
- 10D5
Psychology Assessment Report
Reports a contracted psychologist's assessment under WorkSafeBC's psychology and neuropsychology assessments program.
- Completed by
- Contracted registered psychologist
- Issued by
- WorkSafeBC
- Format
- Word document
- Language
- English
- 83D56
Requisition for Medical Imaging (Form 83D56)
Orders diagnostic imaging for a worker through WorkSafeBC's expedited medical imaging services.
- Completed by
- Physician (specialist or primary care)
- Issued by
- WorkSafeBC
- Language
- English
Insurance claims
-
Pacific Blue Cross's first-time request for extended health coverage of a continuous glucose monitor, approved for one year. The plan member completes Parts 1 and 6, and the physician managing the CGM completes Parts 2 to 5.
- Completed by
- Plan member (Parts 1 and 6); physician managing the CGM (Parts 2 to 5)
- Issued by
- Pacific Blue Cross
- Format
- Fillable PDF
- Language
- English
-
ICBC's first report from the family physician after a crash when the injuries cause missed or modified work, school or training, or significantly impair daily activities. The physician completes the whole report, which also serves as the invoice.
- Completed by
- Family physician
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
-
ICBC's follow-up report from the family physician when a patient injured in a crash isn't recovering as expected, or the diagnosis or care plan changes. The physician completes the whole report, which also serves as the invoice.
- Completed by
- Family physician
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
-
ICBC's first report from the family physician after a crash, for patients whose injuries haven't kept them from work, school or training. The physician completes the whole report, which also serves as the invoice.
- Completed by
- Family physician
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
-
ICBC's report from a consulting physician who sees a patient injured in a crash on referral. The consultant completes the whole report, which also serves as the invoice for the report fee.
- Completed by
- Consulting physician
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
-
Pacific Blue Cross's request to find out in advance whether a member's plan will cover a sleep apnea device such as a CPAP. The member completes Parts 1 and 4, the physician Part 2, and the device provider Part 3.
- Completed by
- Plan member (Parts 1 and 4); physician (Part 2); device provider (Part 3)
- Issued by
- Pacific Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Attending Physician's Statement
Backs a first claim for long-term disability from a BC employee in health care, community social services or the public sector who is covered by an HBT plan.
- Completed by
- Attending physician
- Issued by
- Healthcare Benefit Trust (claims adjudicated by Canada Life)
- Format
- Language
- English
- Form C
Attending Physicians Statement of Continuing Disability
Gives the periodic physician update that keeps an ongoing long-term disability claim under an HBT plan in force.
- Completed by
- Attending physician
- Issued by
- Healthcare Benefit Trust (claims adjudicated by Canada Life)
- Format
- Language
- English
- CL489D
Chiropractic Progress Report
Gives a chiropractor's progress update on an injured claimant, and is completed only when the insurer asks for it.
- Completed by
- Chiropractor
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489G
Counselling Initial Report
Records a clinical counsellor's first assessment of a claimant, submitted once that assessment is done.
- Completed by
- Clinical counsellor
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489H
Counselling Progress Report
Updates the insurer on a claimant's counselling, and a clinical counsellor completes it only when asked.
- Completed by
- Clinical counsellor
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL797
Functional Driver Evaluation
Evaluates an injured customer's functional ability to drive, carried out by an occupational therapist.
- Completed by
- Occupational therapist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL794
Functional Job Match Assessment
Compares an injured customer's demonstrated functional abilities against the demands of their job, as assessed by an occupational therapist.
- Completed by
- Occupational therapist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489K
Kinesiology Progress Report
Gives a kinesiologist's progress update on an injured claimant, and is completed only when the insurer asks for it.
- Completed by
- Kinesiologist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489R
Nurse Practitioner Report
Lets a nurse practitioner report on a claimant's injuries, and is completed only when the insurer requests it.
- Completed by
- Nurse practitioner
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489N
Occupational Therapy Discharge Report
Closes out an injured claimant's occupational therapy with the therapist's discharge findings.
- Completed by
- Occupational therapist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489L
Occupational Therapy Initial Report
Records an occupational therapist's first assessment of an injured claimant at the start of their therapy.
- Completed by
- Occupational therapist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489M
Occupational Therapy Progress Report
Updates the insurer on an injured claimant's occupational therapy while treatment is under way.
- Completed by
- Occupational therapist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL750
Personal Care Assistance Assessment Report
Assesses how much personal care assistance an injured customer needs, based on an occupational therapist's evaluation.
- Completed by
- Occupational therapist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489F
Physiotherapy Progress Report
Gives a physiotherapist's progress update on an injured claimant, and is completed only when the insurer asks for it.
- Completed by
- Physiotherapist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489P
Psychology Initial Report
Records a registered psychologist's first assessment of a claimant, submitted once that assessment is done.
- Completed by
- Registered psychologist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL489Q
Psychology Progress Report
Updates the insurer on a claimant's psychological treatment, and the psychologist completes it only when asked.
- Completed by
- Registered psychologist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
- CL737
Range of motion loss report
Measures a claimant's permanent loss of range of motion for the insurer's permanent impairment assessment, and is completed only on request.
- Completed by
- Physician, chiropractor, kinesiologist, occupational therapist, physiotherapist or RMT
- Issued by
- ICBC
- Format
- Sent for each case
- Language
- English
- CL736
Scarring measurement report
Measures a claimant's permanent scarring to inform the insurer's permanent impairment assessment, and is completed only on request.
- Completed by
- Physician, chiropractor, kinesiologist, occupational therapist, physiotherapist or RMT
- Issued by
- ICBC
- Format
- Sent for each case
- Language
- English
- CL797A
Vehicle Adaptation or Acquisition Request
Asks for a vehicle to be adapted or acquired so an injured customer can travel as driver or passenger, on an occupational therapist's recommendation.
- Completed by
- Occupational therapist
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
Government benefits and tax credits
-
BC's application for the Persons with Disabilities designation. The applicant completes Section 1, a physician or nurse practitioner completes the Medical Report in Section 2, and a prescribed professional completes the Assessor Report in Section 3.
- Completed by
- Applicant (Section 1); physician or nurse practitioner (Section 2, Medical Report); prescribed professional (Section 3, Assessor Report)
- Issued by
- BC Ministry of Social Development and Poverty Reduction
- Format
- Fillable PDF
- Language
- English
-
BC's application for Persons with Persistent Multiple Barriers status on income assistance. A health professional completes the Section 1 health assessment and the applicant completes Section 2, their other barriers to employment.
- Completed by
- Health professional (Section 1, Part C); applicant (Section 1, Part B consent and Section 2)
- Issued by
- BC Ministry of Social Development and Poverty Reduction
- Format
- Fillable PDF
- Language
- English
- HR2847
Application for Monthly Nutritional Supplement
Asks for a monthly supplement payment for someone designated PWD whose long-term, worsening health problem requires additional nutrition or vitamins.
- Completed by
- Medical practitioner, nurse practitioner or registered dietitian
- Issued by
- BC SDPR
- Format
- Sent for each case
- Language
- English
- HR3727
Breathing Device Request and Justification
Requests a ministry-funded breathing device such as CPAP or BiPAP equipment for an assistance client, and also handles Life-Threatening Health Need requests.
- Completed by
- Section 2: medical practitioner or nurse practitioner (or attach a written prescription). Section 3: respiratory therapist.
- Issued by
- BC SDPR
- Format
- Fillable PDF
- Language
- English
- REG-005
Housing Registry Supplemental Application Form
Describes unusual circumstances, for instance a serious health condition aggravated by the applicant's present housing, to back a subsidized housing application that an outside party then verifies.
- Completed by
- Third-party verifier; for health conditions a physician, RN or registered psychiatric nurse, OT or registered social worker (not a landlord, friend, neighbour or relative)
- Issued by
- BC Housing (The Housing Registry)
- Format
- Language
- English
- HR2138
Medical Equipment Request and Justification
Asks the ministry to pay for equipment or devices an assistance client essentially needs, choosing the cheapest suitable item, with a therapist's assessment as support.
- Completed by
- Section 2: medical practitioner or nurse practitioner. Section 3: occupational, physical or respiratory therapist.
- Issued by
- BC SDPR
- Format
- Sent for each case
- Language
- English
- HR3103
Medical Report – Child
Describes a child's condition and the care it needs, so a parent on assistance can be excused from work duties when the child's needs rule out a 30-hour week.
- Completed by
- Medical practitioner (physician registered with CPSBC)
- Issued by
- BC SDPR
- Format
- Sent for each case
- Language
- English
- HR3069
Medical Report – Employability
Tells the ministry how a client's health problem limits looking for, taking or staying in work, for medical exemptions or Expected to Work categorisation.
- Completed by
- Medical practitioner (physician registered with CPSBC; GP or specialist)
- Issued by
- BC SDPR
- Format
- Sent for each case
- Language
- English
- HR2894
Orthoses Request and Justification
Seeks pre-authorization for ministry-paid custom or ready-made orthoses and knee braces, supported by a separate assessment from an orthotist, pedorthist or therapist.
- Completed by
- Prescribing practitioner (Section 2); orthotist, pedorthist, occupational therapist or physical therapist (Section 3 Assessment)
- Issued by
- BC SDPR
- Format
- Language
- English
- HR3635
Request For Diet Supplement
Confirms that a client needs a therapeutic diet, such as diabetic, gluten-free, ketogenic or dysphagia diets, so they can receive a diet supplement with their assistance.
- Completed by
- Physician, nurse practitioner or registered dietitian
- Issued by
- BC SDPR
- Format
- Fillable PDF
- Language
- English
-
StudentAid BC Disability Verification Form
Confirms a student's permanent or long-lasting disability so they can qualify for federal and provincial disability grants; the right assessor depends on whether the condition is visual, auditory or other.
- Completed by
- Qualified medical assessor in Canada: physician, nurse practitioner or psychologist (most conditions); ophthalmologist, optometrist or orthoptist (visual); certified audiologist (auditory)
- Issued by
- StudentAid BC
- Format
- Fillable PDF
- Language
- English
Drug coverage
-
Registers a palliative patient for PharmaCare Plan P drug coverage and a home and community care assessment for supplies and equipment. A physician or nurse practitioner certifies eligibility and the patient signs consent.
- Completed by
- Medical or nurse practitioner; patient or legal representative signs consent
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF
- Language
- English
- HLTH 5479
PharmaCare Compound Coverage Request
BC PharmaCare's Special Authority request for coverage of a non-benefit compounded prescription. The prescriber documents why a compound is the last resort and signs, and the compounding pharmacy supplies pricing.
- Completed by
- Prescriber; the compounding pharmacy supplies pricing
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF
- Language
- English
- HLTH 5328
PharmaCare Special Authority Request
BC PharmaCare's general Special Authority request, used when no drug-specific form exists. The prescriber completes and signs every section.
- Completed by
- Prescriber (physician, nurse practitioner or other licensed prescriber)
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
-
BC PharmaCare's Special Authority request for the mometasone, indacaterol and glycopyrronium triple inhaler in asthma. The prescriber completes the whole form.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for CGRP antagonists to prevent episodic or chronic migraine, covering initial requests, switches and renewals. The prescriber completes the whole form.
- Completed by
- Prescriber experienced in managing migraine
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for icosapent ethyl with a statin for secondary prevention of cardiovascular disease. The prescriber completes the whole form.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for ticagrelor 90 mg with ASA after acute coronary syndrome. The prescriber picks one of two coverage routes and signs.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
-
BC PharmaCare's Special Authority request for proton pump inhibitor coverage under the Reference Drug Program. The prescriber names the diagnosis and completes one medication section.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
-
BC PharmaCare's Special Authority request for up to 100 extra blood glucose test strips a year above the annual limit. A prescriber or diabetes education centre completes it.
- Completed by
- Prescriber or diabetes education centre
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
-
BC PharmaCare's Special Authority request for angiotensin receptor blockers under the Reference Drug Program. The prescriber completes the whole form, choosing the reference or non-reference sections.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for dabigatran in non-valvular atrial fibrillation. The prescriber certifies the diagnosis, a stroke risk factor and why warfarin isn't suitable.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
-
BC PharmaCare's Special Authority request for outpatient low molecular weight heparin. The prescriber picks one drug and one indication and signs.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
-
BC PharmaCare's Special Authority request for low molecular weight heparin to treat venous thromboembolism associated with cancer. The prescriber requests initial coverage or an exceptional renewal and signs.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
-
BC PharmaCare's Special Authority request for cholinesterase inhibitors in mild to moderate Alzheimer's disease and mixed dementia. The prescriber completes the initial, switching or renewal section and signs.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
- HLTH 5493
Special Authority Request, Evolocumab for Heterozygous Familial Hypercholesterolemia (HeFH)
BC PharmaCare's Special Authority request for evolocumab in adults with heterozygous familial hypercholesterolemia who don't reach lipid targets on a statin and ezetimibe. The prescriber completes the whole form.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
- HLTH 5856
Special Authority Request, Finerenone
BC PharmaCare's Special Authority request for finerenone in adults with type 2 diabetes and chronic kidney disease. The prescriber completes the whole form.
- Completed by
- Prescriber experienced in CKD and type 2 diabetes, or in consultation with a nephrologist
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for continuous or flash glucose monitors in people with diabetes on intensive insulin therapy. The prescriber completes the whole form, for initial coverage or renewal.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for limited coverage COPD inhalers: LAMA, LABA, LAMA/LABA, ICS/LABA and triple therapy. The prescriber completes the section for the inhaler class and signs.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
-
BC PharmaCare's Special Authority request for intravenous iron sucrose, iron isomaltoside or ferric carboxymaltose in iron deficiency anemia. The prescriber completes the whole form.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for long-acting ADHD stimulants and atomoxetine. The prescriber confirms the diagnosis, documents earlier trials and signs.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or Special Authority eForm
- Language
- English
- HLTH 5483
Special Authority Request, Rifaximin
BC PharmaCare's Special Authority request for rifaximin 550 mg to reduce recurrence of overt hepatic encephalopathy. A gastroenterologist or internal medicine specialist completes the whole form.
- Completed by
- Gastroenterologist or internal medicine specialist
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for sacubitril-valsartan in heart failure with reduced ejection fraction. The prescriber completes the whole form.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for semaglutide injection in type 2 diabetes after metformin. The prescriber completes the whole form.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
-
BC PharmaCare's Special Authority request for a DPP-4 inhibitor (linagliptin or saxagliptin) or pioglitazone as third-line therapy for type 2 diabetes. The prescriber completes the whole form.
- Completed by
- Prescriber
- Issued by
- BC PharmaCare, Ministry of Health
- Format
- Fillable PDF, or PharmaCare SA eForm
- Language
- English
- HLTH 3497
Application for PharmaCare Plan G (Psychiatric Medication Coverage)
Applies for free psychiatric drug coverage when a patient has clinical need and financial hardship, with a three-month bridge available after hours.
- Completed by
- Prescribing practitioner (physician, NP, or other prescriber); the local MHSU/CYMH centre director confirms eligibility. Bridge coverage: ED, RAAC, UPCC, corrections or health-authority prescriber.
- Issued by
- BC PharmaCare / Ministry of Health
- Format
- Fillable PDF
- Language
- English
- 0199.022
Drug Eligibility Inquiry Form
Asks for prior authorization of drugs that need approval before a Blue Chip plan will cover them.
- Completed by
- Physician
- Issued by
- Pacific Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Special Authority request forms by condition (drug-, device- and supply-specific)
Groups the request forms prescribers fill out, one per drug, device or supply, to get PharmaCare coverage for things like diabetes devices, GLP-1s, biologics and ADHD medication.
- Completed by
- Prescriber (physician or nurse practitioner; some forms are specialist-only)
- Issued by
- BC PharmaCare
- Format
- Language
- English
Driving and licensing
-
RoadSafetyBC's form for reporting a patient whose medical condition may make driving unsafe. A physician, nurse practitioner, optometrist or psychologist completes and signs it.
- Completed by
- Physician, nurse practitioner, optometrist or psychologist
- Issued by
- RoadSafetyBC
- Format
- Fillable PDF
- Language
- English
- MV2011D
Driver's Medical Examination Report (DMER)
Assesses fitness to drive for drivers over 79, commercial drivers on a set schedule (yellow DMER) and anyone with a known or suspected condition (blue DMER).
- Completed by
- Physician or NP
- Issued by
- RoadSafetyBC
- Format
- Sent for each case
- Language
- English
Mental health and medico-legal
- HLTH 3519
Certificate of Discharge
The certificate confirming a patient was discharged from a designated facility under BC's Mental Health Act. The director completes and signs it on request.
- Completed by
- Director of the designated facility
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
-
The consent form for treatment of an involuntary patient under BC's Mental Health Act. Either the patient or the director signs the authorization, and a physician signs a statement about the patient's capability.
- Completed by
- Patient (option A) or the director or person authorized by the director (option B); physician (capability statement)
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
-
The first certificate for involuntary admission under BC's Mental Health Act. The examining physician or nurse practitioner completes Section 1, and the facility's Mental Health Act director or delegate completes Section 2.
- Completed by
- Examining physician or nurse practitioner (Section 1); MHA director or delegate of the designated facility (Section 2)
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
- HLTH 3520
Leave Authorization
The authorization releasing an involuntary patient on leave from a designated facility under section 37 of BC's Mental Health Act. The director sets the conditions and names a community physician, and the patient signs that the conditions were explained.
- Completed by
- Director of the designated facility; patient confirms the conditions were explained
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
- HLTH 3512
Medical Report (Second Medical Opinion)
The report a physician writes to a facility director after giving a second medical opinion on an involuntary patient's treatment under BC's Mental Health Act. The physician completes it and the director acknowledges receipt.
- Completed by
- Physician giving the second medical opinion; director acknowledges receipt
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
-
The renewal certificate that extends an involuntary patient's detention under section 24 of BC's Mental Health Act. The facility director, or a physician the director authorizes, examines the patient and completes it.
- Completed by
- Director of the designated facility, or a physician authorized by the director
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
- HLTH 3511
Request for Second Medical Opinion
The request an involuntary patient, or someone on their behalf, makes for a second medical opinion on their treatment under BC's Mental Health Act. The patient or their representative completes the whole form.
- Completed by
- Involuntary patient, or a person on their behalf, with a witness
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
-
The second certificate that continues involuntary admission under BC's Mental Health Act beyond 48 hours. A physician completes Section 1, and the facility's Mental Health Act director or delegate completes Section 2.
- Completed by
- Examining physician (Section 1); MHA director or delegate of the designated facility (Section 2)
- Issued by
- BC Ministry of Health
- Format
- Fillable PDF
- Language
- English
Parking, transit and travel
-
TransLink's application for HandyDART door-to-door service and the HandyCard concession card in Metro Vancouver. The applicant completes the application and an approved authority, such as a physician or nurse practitioner, completes the verification.
- Completed by
- Applicant (application sections); approved authority (Approved Authority Verification)
- Issued by
- TransLink (Coast Mountain Bus Company, Access Transit)
- Format
- Fillable PDF
- Language
- English
-
BC Transit's handyDART application package for Abbotsford, Mission and the Fraser Valley Regional District. The applicant completes the H1 application, and a health care practitioner can add the optional H4 Medical Verification of Eligibility.
- Completed by
- Applicant or legal representative (H1 application); qualified health care or social services practitioner (optional H4)
- Issued by
- BC Transit, Central Fraser Valley handyDART
- Format
- Fillable PDF
- Language
- English
-
BC Transit's form for a health care or social services practitioner to describe a handyDART applicant's ability to use the regular bus. The practitioner completes and signs it.
- Completed by
- Medical doctor, RN, registered psychiatric nurse, OT, PT, rehab practitioner or social worker familiar with the applicant's mobility
- Issued by
- BC Transit
- Format
- Fillable PDF
- Language
- English
-
SPARC BC's application for an accessible parking permit for people with a mobility-related disability. The applicant completes the personal, payment and declaration steps, and a physician completes the assessment and recommendation.
- Completed by
- Applicant (Steps 1, 2 and 6 to 8); physician (Steps 3 to 5)
- Issued by
- SPARC BC
- Format
- Fillable PDF
- Language
- English
-
Accessible Fare Identification Card Application
Confirms a resident's disability when other proof is unavailable, so they and a personal attendant can get discounted ferry fares.
- Completed by
- Physician or nurse practitioner
- Issued by
- BC Ferries
- Format
- Language
- English
-
HandyDART and HandyCard Application Form
Confirms the medical conditions that prevent a patient from riding regular transit, so they can qualify for HandyDART door-to-door service and a companion fare pass in Metro Vancouver.
- Completed by
- Approved authority: licensed physician/surgeon, RN, LPN, NP, OT, physiotherapist, social worker, licensed optometrist or psychologist
- Issued by
- TransLink (Access Transit, Coast Mountain Bus Company)
- Format
- Fillable PDF
- Language
- English
-
Parking Permit Application
Applies for an accessible parking permit for a patient with a mobility-related disability, whether permanent, permanent but may improve, or temporary for up to 12 months.
- Completed by
- Physician
- Issued by
- SPARC BC
- Format
- Fillable PDF
- Language
- English
Health programs
- CF2158
At Home Program Application
Enrols a child in medical benefits and respite when severe disability or complex health needs leave them reliant on others for most daily living activities.
- Completed by
- Physician or nurse practitioner, together with the parent/guardian
- Issued by
- BC MCFD (At Home Program)
- Format
- Fillable PDF
- Language
- English
- CF2183
At Home Program Request for Medical Supplies
Asks the program to pay for an enrolled child's medical and incontinence supplies, with the clinician's rationale.
- Completed by
- Medical professional recommending the supplies (e.g., physician or NP)
- Issued by
- BC MCFD (At Home Program)
- Format
- Fillable PDF
- Language
- English
- CF2184
At Home Program Request for Optical Benefits
Asks the program to cover prescription glasses an enrolled child needs due to their disability or a specific medical diagnosis.
- Completed by
- Physician or nurse practitioner
- Issued by
- BC MCFD (At Home Program)
- Format
- Language
- English
- CF2182
At Home Program School-Aged Extended Therapies Request
Asks the program to fund extra OT, PT, speech-language, chiropractic and massage sessions for an enrolled child aged five or older.
- Completed by
- Treating therapist (OT, PT or SLP) with the family; physician or nurse practitioner referral for massage or chiropractic
- Issued by
- BC MCFD (At Home Program)
- Format
- Fillable PDF
- Language
- English
- HLTH 2810
Out-of-Country Health Services Funding Application
Requests advance MSP approval to fund elective non-laboratory treatment abroad that cannot be had in Canada; it is incomplete without the attending BC specialist's signature.
- Completed by
- Attending BC specialist (the form is incomplete without their signature)
- Issued by
- BC Ministry of Health – MSP (HIBC)
- Format
- Fillable PDF
- Language
- English
- HLTH 2900
Request for Travel Assistance
Completed when a patient is referred, to get discounted travel to insured specialist care that is not offered in their area.
- Completed by
- Referring physician or nurse practitioner office (Part One); hospital staff (Part Two, return by ambulance)
- Issued by
- BC Ministry of Health – Travel Assistance Program (HIBC)
- Format
- Sent for each case
- Language
- English
Other forms
- CL392
Health service provider invoice
Provides an invoice template for providers like nurse practitioners and nurses whose usual invoice does not satisfy the insurer's requirements.
- Completed by
- Health care provider
- Issued by
- ICBC
- Format
- Language
- English
- 83D556
Physician Consult Report Fax Cover Sheet (Form 83D556)
The cover sheet that is recommended when a specialist faxes a consultation report or a follow-up report to the compensation board.
- Completed by
- Specialist physician (or office staff)
- Issued by
- WorkSafeBC
- Language
- English
Alberta
Lab and imaging requisitions
-
Alberta Precision Laboratories' requisition for first trimester screening with nuchal translucency and serum markers, for ultrasounds done in Edmonton, North and Central zones. The patient answers the background questions, the authorizing provider orders, and the sonographer records the measurements.
- Completed by
- Patient (background questions); authorizing provider; NT-certified sonographer (ultrasound section)
- Issued by
- Alberta Precision Laboratories
- Format
- Fillable PDF
- Language
- English
-
Alberta Precision Laboratories' requisition for QuantiFERON interferon-gamma release testing for latent TB. The ordering clinician completes it, chooses one indication and signs it.
- Completed by
- Ordering (approving) clinician
- Issued by
- Alberta Precision Laboratories
- Format
- Fillable PDF
- Language
- English
- 21302
General Laboratory Requisition
Orders everyday blood work plus common tests in chemistry, hematology, serology and urine, drug levels, cardiovascular risk and screening at Alberta's community laboratories.
- Completed by
- Authorizing provider (prescriber ordering the tests and acting on results); collector completes collection fields
- Issued by
- Alberta Precision Laboratories (Alberta Health Services)
- Format
- Language
- English
Referrals
- 21396
Connect Care Referral
The general Alberta Health Services referral form for consultation or e-Consult requests to services that use Connect Care. The referring provider or their office completes it.
- Completed by
- Referring provider or source, or office staff on their behalf
- Issued by
- Alberta Health Services
- Format
- Fillable PDF
- Language
- English
Workers' compensation
-
WCB-Alberta's referral for a one-time orthopaedic opinion on an injured worker's diagnosis and management. The treating physician completes it.
- Completed by
- Treating (referring) physician
- Issued by
- Workers' Compensation Board of Alberta
- Format
- Fillable PDF
- Language
- English
-
WCB-Alberta's report from the physician authorizing medical cannabis for an injured worker, due at least every three months. The physician completes it.
- Completed by
- Physician authorizing and managing medical cannabis
- Issued by
- Workers' Compensation Board of Alberta
- Format
- Fillable PDF
- Language
- English
- M007
Acupuncture first report - M007
Reports an acupuncturist's findings after examining a worker who was referred for treatment on a WCB claim.
- Completed by
- Acupuncturist
- Issued by
- WCB-Alberta
- Format
- Fillable PDF
- Language
- English
- M007A
Acupuncture progress/discharge report - M007A
Reports an acupuncturist's progress with a worker or their discharge from acupuncture.
- Completed by
- Acupuncturist
- Issued by
- WCB-Alberta
- Format
- Language
- English
- C056
Chiro first report - C056
Reports a chiropractor's findings after the first assessment of an injured worker.
- Completed by
- Chiropractor
- Issued by
- WCB-Alberta
- Format
- Fillable PDF
- Language
- English
- C352
Chiro progress/discharge report - C352
Reports a chiropractor's progress at three weeks, or the discharge of the worker from care.
- Completed by
- Chiropractor
- Issued by
- WCB-Alberta
- Format
- Fillable PDF
- Language
- English
- C055
Dental report - C055/C887
Reports a work-related dental injury, the emergency treatment given and the treatment proposed.
- Completed by
- Dentist
- Issued by
- WCB-Alberta
- Format
- Language
- English
- C884
Denturist report - C884
Reports damage to a worker's dentures caused by a work injury, completed by the denturist who assessed them.
- Completed by
- Denturist
- Issued by
- WCB-Alberta
- Format
- Language
- English
- C662
Hearing loss assessment - C662
Records an audiologist's assessment, including history, audiogram, tympanometry and recommendations, to support a hearing loss claim.
- Completed by
- Audiologist (hearing loss services provider)
- Issued by
- WCB-Alberta
- Format
- Language
- English
-
Home health care reports
Gathers the initial, progress and discharge reports that home health care providers send for WCB-authorized home care services.
- Completed by
- Home health care nurse / provider
- Issued by
- WCB-Alberta
- Format
- Word document
- Language
- English
-
Hospital physiotherapy, hand clinic and occupational therapy reports
Collects the reports on assessment, progress and discharge for physiotherapy, hand clinic and occupational therapy delivered in hospitals under a WCB claim.
- Completed by
- Hospital physiotherapists, hand therapists and occupational therapists
- Issued by
- WCB-Alberta
- Format
- Language
- English
- C568A
Medical Consultation Report (C568A)
Bills a specialist's consultations, follow-ups and surgery, or any physician's WCB-requested supplementary report, with the narrative report attached.
- Completed by
- Specialist physician (and any physician billing a WCB-requested supplementary report)
- Issued by
- WCB-Alberta
- Format
- Online portal or EMR
- Language
- English
- C914
Medication management report (C914)
Reports how a worker's opioid or other medication is being managed, including work capability and restrictions, on a WCB claim.
- Completed by
- Physician
- Issued by
- WCB-Alberta
- Format
- Language
- English
- C1392
Mental Health First Report - C1392
Reports a suspected work-related mental health condition when a psychologist or social worker first sees the client.
- Completed by
- Psychologist or clinical/master's-level social worker (any regulated professional with a duty to report)
- Issued by
- WCB-Alberta
- Format
- Word document
- Language
- English
- C914N
Nurse practitioner medication management report (C914N)
Lets a nurse practitioner report on medication and opioid management for a worker on a WCB claim.
- Completed by
- Nurse practitioner
- Issued by
- WCB-Alberta
- Format
- Language
- English
-
Occupational therapy contract report forms
Gathers the assessment, progress and discharge templates used by occupational therapists contracted by WCB.
- Completed by
- Contracted occupational therapist
- Issued by
- WCB-Alberta
- Format
- Word document
- Language
- English
- C709
On-site health centre report - C709
A clinician at a workplace's on-site health centre uses this to report on a worker's injury or the treatment given.
- Completed by
- On-site health centre clinician
- Issued by
- WCB-Alberta
- Format
- Language
- English
- C913
Opioid (narcotics) treatment agreement (C913)
The written opioid therapy agreement between a worker and the physician who prescribes, filed with a WCB claim.
- Completed by
- Prescribing physician and worker
- Issued by
- WCB-Alberta
- Format
- Language
- English
- C942
Opioid risk assessment checklist (C942)
A checklist that physicians use to screen for opioid risk while they manage a worker's opioid therapy under a WCB claim.
- Completed by
- Physician
- Issued by
- WCB-Alberta
- Format
- Language
- English
- C050
Physician first report (C050)
A physician who is not a specialist uses this single form as both the first report and the invoice for the first visit after a work injury.
- Completed by
- Physician (general practitioner / non-specialist)
- Issued by
- WCB-Alberta
- Format
- Online portal or EMR
- Language
- English
- C151
Physician progress report (C151)
Updates a non-specialist physician's first report when relevant changes have occurred, and doubles as the invoice for the follow-up.
- Completed by
- Physician (general practitioner / non-specialist)
- Issued by
- WCB-Alberta
- Format
- Online portal or EMR
- Language
- English
- C534
Physiotherapy services abbreviated progress report - C534
Gives a short physiotherapy progress update on an injured worker when a full report is not needed.
- Completed by
- Physiotherapist
- Issued by
- WCB-Alberta
- Format
- Language
- English
- C534
Physiotherapy services comprehensive progress/discharge report - C534
A physiotherapist's detailed progress or discharge report that covers the worker's status for returning to work along with recommendations.
- Completed by
- Physiotherapist
- Issued by
- WCB-Alberta
- Format
- Fillable PDF
- Language
- English
- C533
Physiotherapy services first report - C533
Records a physiotherapist's first assessment of an injured worker, sent to the board at the start of physiotherapy treatment.
- Completed by
- Physiotherapist
- Issued by
- WCB-Alberta
- Format
- Fillable PDF
- Language
- English
- C988
Prosthetic and orthotic services physician assessment - C988
Supports a request for a prosthetic or orthotic device with the physician's assessment of the worker.
- Completed by
- Physician
- Issued by
- WCB-Alberta
- Format
- Word document
- Language
- English
- C1147
Psychology counselling extension report - C1147
Requests more counselling sessions for a worker, filed by a contracted psychology provider.
- Completed by
- WCB-authorized psychologist or master's-level social worker
- Issued by
- WCB-Alberta
- Format
- Word document
- Language
- English
- C853
Psychology discharge counselling report - C853
Lets a contracted psychology provider report on discharge from counselling for a worker on a WCB claim.
- Completed by
- WCB-authorized psychologist or master's-level social worker
- Issued by
- WCB-Alberta
- Format
- Word document
- Language
- English
- C851
Psychology initial counselling report - C851
Lets a contracted psychology provider report on the first counselling session for a worker on a WCB claim.
- Completed by
- WCB-authorized psychologist or master's-level social worker
- Issued by
- WCB-Alberta
- Format
- Word document
- Language
- English
- C852
Psychology progress counselling report - C852
Lets a contracted psychology provider report on counselling progress for a worker on a WCB claim.
- Completed by
- WCB-authorized psychologist or master's-level social worker
- Issued by
- WCB-Alberta
- Format
- Word document
- Language
- English
Insurance claims
-
Alberta Blue Cross's physician statement for a group critical illness claim. The plan member completes Section 1 and the attending physician completes the Attending Physician Statement.
- Completed by
- Plan member (Section 1); attending physician (Section 2)
- Issued by
- Alberta Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Alberta Blue Cross's copy of the industry initial medical statement for a new short-term disability claim. The patient completes Section 1 and the doctor or other medical provider completes Section 2.
- Completed by
- Patient (Section 1); family physician, specialist or other medical provider (Section 2)
- Issued by
- Alberta Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Care and Treatment Concluding Report (Mental Health)
Records how a patient's mental health treatment turned out and the suggested next steps when treatment under Care-First comes to an end.
- Completed by
- Health care practitioner (mental health)
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Care and Treatment Concluding Report (Physical)
Documents treatment outcomes and next steps when a patient's customized physical treatment under Care-First ends.
- Completed by
- Health care practitioner
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Care and Treatment Progress Form (Mental Health)
Updates the insurer on a patient's mental health recovery, response to treatment and any change in treatment needs.
- Completed by
- Health care practitioner (mental health)
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Care and Treatment Progress Form (Physical)
Updates the insurer on a patient's physical recovery, response to treatment and any change in treatment needs.
- Completed by
- Health care practitioner
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Care and Treatment Request (Physical)
Asks the insurer to approve a customized physical treatment plan; it does not establish a diagnosis.
- Completed by
- Health care practitioner
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
- MI-3
Certified Examiner Prescribed Form for Providing an Opinion
A certified examiner states whether the claimant has a minor injury, as defined by the Minor Injury Regulation.
- Completed by
- Certified examiner (health professional on the Superintendent's Certified Examiner Register)
- Issued by
- Alberta Superintendent of Insurance (Treasury Board and Finance)
- Format
- Fillable PDF
- Language
- English
- AB-1A
Claim for Disability Benefits
A claim for disability income benefits under Section B, in which a physician certifies that the claimant is disabled.
- Completed by
- Physician
- Issued by
- Alberta Superintendent of Insurance (Treasury Board and Finance)
- Format
- Fillable PDF
- Language
- English
-
Combined Program of Care Initial Assessment and Care and Treatment Request
Combines the Program of Care initial assessment with a treatment request, for claims that include both Program of Care injuries and injuries needing customized treatment.
- Completed by
- Health care practitioner
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
- AB-4
Concluding Report
Sums up the treatment given, the claimant's status at discharge and whether more care is needed once treatment under the Diagnostic and Treatment Protocols finishes.
- Completed by
- Primary health care practitioner
- Issued by
- Alberta Superintendent of Insurance (Treasury Board and Finance)
- Format
- Fillable PDF
- Language
- English
-
Daily Living Assistance (DLA) Assessment Tool Report
Assesses how well a patient can manage daily and instrumental activities after an accident, when the insurer asks, to decide the Daily Living Assistance benefit.
- Completed by
- Health care practitioner (insurer-initiated)
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Initial Assessment and Care and Treatment Request (Mental Health)
Pairs a mental health assessment and diagnosis with a proposed customized treatment plan, and the insurer has to approve the plan before any treatment starts.
- Completed by
- Health care practitioner (mental health)
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Initial Assessment and Care and Treatment Request (Physical)
Pairs a physical assessment and diagnosis with a proposed customized treatment plan, and the insurer has to approve the plan before any treatment starts.
- Completed by
- Health care practitioner
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Initial Disability Insurance Medical Statement
Provides the medical statement that supports a disability insurance claim, in Alberta Blue Cross's copy of the industry initial statement.
- Completed by
- Attending physician or other medical provider
- Issued by
- Alberta Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Medical Assessor's Report
Reports the findings of an independent multidisciplinary medical assessment arranged under Care-First.
- Completed by
- Primary medical assessor
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Program of Care Initial Assessment
Captures the patient's functional status, how the injury affects them, the diagnosis and treatment needs, to decide whether they qualify for Care-First's Program of Care.
- Completed by
- Health care practitioner
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Program of Care Phase 1 Report
After six weeks of treatment in the Program of Care, reports the patient's functional status, how they responded, and how outcome measures are moving.
- Completed by
- Health care practitioner
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
-
Program of Care Phase 2 / Concluding Report
Reports functional status and progress on outcome measures when the Program of Care treatment is finished.
- Completed by
- Health care practitioner
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
- AB-3
Progress Report
Reports a claimant's recovery progress, usually when the insurer asks for an update.
- Completed by
- Primary health care practitioner
- Issued by
- Alberta Superintendent of Insurance (Treasury Board and Finance)
- Format
- Fillable PDF
- Language
- English
-
Range of Motion Assessment
At the insurer's request, objectively measures how far joints move, to judge whether there is a permanent loss of movement that qualifies for a permanent impairment benefit.
- Completed by
- Health care practitioner (insurer-initiated)
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
- AB-5
Referral
Sends a claimant to another practitioner or to an Injury Management Consultant, and includes details of the injury, tests done and treatment so far.
- Completed by
- Primary health care practitioner
- Issued by
- Alberta Superintendent of Insurance (Treasury Board and Finance)
- Format
- Fillable PDF
- Language
- English
-
Scarring Assessment
At the insurer's request, records scarring or other lasting changes to the body so that eligibility for a permanent impairment benefit can be decided.
- Completed by
- Health care practitioner (insurer-initiated)
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
- AB-2
Treatment Plan
Gives the patient's status and a treatment plan for sprains, strains or whiplash under Alberta's protocols regulation, where only the listed treatment is pre-authorized.
- Completed by
- Primary health care practitioner (physician, chiropractor or physical therapist)
- Issued by
- Alberta Superintendent of Insurance (Treasury Board and Finance)
- Format
- Fillable PDF
- Language
- English
Government benefits and tax credits
-
Alberta's medical report for an AISH or ADAP application. A physician or nurse practitioner registered in Alberta completes and signs it; the applicant fills in a separate application.
- Completed by
- Physician registered with the CPSA or nurse practitioner registered with the CRNA
- Issued by
- Government of Alberta, Assisted Living and Social Services
- Format
- Fillable PDF
- Language
- English
-
ASA Disability Verification
Confirms a permanent or prolonged disability so that a student can get funding from Alberta Student Aid and the Canada grants for students with disabilities.
- Completed by
- Condition-specific medical assessor: physician, registered psychologist, psychiatrist, neuropsychologist, audiologist, optometrist/ophthalmologist, speech-language pathologist or medical specialist
- Issued by
- Alberta Student Aid
- Format
- Fillable PDF
- Language
- English
- LA163
Confidential Medical Statement
The physician's statement that accompanies an application to the Local Authorities Pension Plan for a pension based on partial or total disability.
- Completed by
- Physician
- Issued by
- Local Authorities Pension Plan (LAPP)
- Format
- Language
- English
- PS163
Confidential Medical Statement
The physician's statement that accompanies an application to the Alberta Public Service Pension Plan for a pension based on partial or total disability.
- Completed by
- Physician
- Issued by
- Public Service Pension Plan (Alberta)
- Format
- Language
- English
Drug coverage
- ABC 60012
DPP-4/SGLT2 Inhibitors / GLP-1 Receptor Agonists Special Authorization Request Form
Asks for special authorization to cover certain drugs for type 2 diabetes, among them SGLT2 inhibitors, DPP-4 inhibitors and semaglutide, through Alberta's government-sponsored programs for drugs.
- Completed by
- Authorized prescriber (CPSA, CARNA, ACP, ACO, ADA+C or other registration)
- Issued by
- Alberta Blue Cross (Alberta government-sponsored drug programs)
- Format
- Fillable PDF
- Language
- English
- ABC 60015
Drug Special Authorization Request
Asks for coverage of a drug listed in the Alberta Drug Benefit List if there is no special authorization form made for that particular drug.
- Completed by
- Authorized prescriber (physician, nurse practitioner, pharmacist, optometrist or dentist, per the registration options on the form)
- Issued by
- Alberta Blue Cross (Alberta government-sponsored drug programs)
- Format
- Fillable PDF
- Language
- English
-
Drug-specific Special Authorization Request Forms (Alberta Drug Benefit List)
Collects the drug-specific forms prescribers use to request special authorization for coverage under Alberta government-sponsored drug programs.
- Completed by
- Authorized prescriber (e.g., physician, dentist or optometrist); the patient may also need to sign some forms
- Issued by
- Alberta Blue Cross (Alberta government-sponsored drug programs)
- Format
- Fillable PDF
- Language
- English
- AHC0222
Palliative Coverage Program form
Enrols a palliative patient who lives in a hospice or at home in the Alberta program that pays for ground ambulance, diabetes supplies and eligible drugs.
- Completed by
- Patient or guardian and a physician or nurse practitioner (both must complete and sign)
- Issued by
- Alberta Health (AHCIP supplementary benefits)
- Format
- Fillable PDF
- Language
- English
- ABC 60130
Special Authorization Request Form – Liraglutide / Naltrexone + Bupropion / Semaglutide / Tirzepatide for Weight Loss
Requests special authorization for weight-loss drugs such as liraglutide, semaglutide and tirzepatide under Alberta Blue Cross plans.
- Completed by
- Prescriber
- Issued by
- Alberta Blue Cross
- Format
- Fillable PDF
- Language
- English
Driving and licensing
-
Alberta's standard driver medical examination form. A physician or nurse practitioner completes the medical history, examination and certificate; the applicant signs the operator's certificate and waiver.
- Completed by
- Any Canadian-licensed physician or nurse practitioner; the applicant signs Part C
- Issued by
- Alberta Transportation and Economic Corridors, Driver Fitness and Monitoring
- Format
- Fillable PDF
- Language
- English
- TRANS3193
Special Medical Examination for Motor Vehicle Operators
Gives Alberta Transportation medical information on a driver beyond the standard driver medical, either on request or when the examiner chooses to add it.
- Completed by
- Examining physician or nurse practitioner (driver completes identification and the Applicant's Certificate and Waiver)
- Issued by
- Alberta Transportation
- Format
- Fillable PDF
- Language
- English
- TRANS3156
Visual Referral Report
An eye specialist reports their findings on a driver who might have failed to reach the basic standard for vision at the screening.
- Completed by
- Vision specialist (optometrist or ophthalmologist)
- Issued by
- Alberta Transportation
- Format
- Fillable PDF
- Language
- English
Mental health and medico-legal
- MH1977
Form 1 - Admission Certificate
Authorizes taking someone to a facility and holding them there for examination, and a second certificate turns them into a formal patient for a month.
- Completed by
- Physician or other qualified health professional (including a nurse practitioner) who examined the person
- Issued by
- Alberta Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English
- MH2000
Form 19 - Issuance of Community Treatment Order
Allows two qualified health professionals, one of them a psychiatrist, to order a community treatment order lasting six months that includes a treatment and care plan, consent and supervision.
- Completed by
- Issuing qualified health professional and a second examining qualified health professional, one of whom is a psychiatrist (treatment providers sign Part III, supervising QHP Part IV, person or substitute decision-maker Part V)
- Issued by
- Alberta Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English
- MH1978
Form 2 - Renewal Certificate
Renews a formal patient's detention under Alberta's Mental Health Act, for one month, then another month, then for periods of up to six months.
- Completed by
- Psychiatrist or other qualified health professional (two certificates: at least one by a psychiatrist and at least one by a member of the facility staff)
- Issued by
- Alberta Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English
- MH2001
Form 20 - Renewal of Community Treatment Order
Extends a community treatment order in Alberta by six months after two qualified professionals, including a psychiatrist, have each examined the patient separately.
- Completed by
- Issuing qualified health professional for the renewal and a second examining qualified health professional, one of whom is a psychiatrist (providers, supervising QHP and person or substitute decision-maker sign their parts)
- Issued by
- Alberta Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English
Parking, transit and travel
- TS 5265
Calgary Transit Access Application
Describes how a patient's condition affects their ability to use Calgary buses and CTrain, to decide eligibility for Calgary's paratransit service.
- Completed by
- Licensed health care professional who has treated the applicant (not a friend or family member)
- Issued by
- Calgary Transit Access (City of Calgary)
- Format
- Fillable PDF
- Language
- English
- REG3164
Parking Placards for People with Disabilities Application
Certifies a patient's eligibility for a temporary, five-year or permanent disability parking placard in Alberta.
- Completed by
- Physician, surgeon, NP, occupational therapist, physiotherapist/physical therapist, podiatrist or chiropractor
- Issued by
- Service Alberta (Registries)
- Format
- Fillable PDF
- Language
- English
Health programs
- AADL13197
Eligibility Summary for Bath Lifts
Summarizes the assessor's findings on client weight, recline, care team, bathroom and transfers to support an AADL-funded bath lift.
- Completed by
- AADL authorizer (occupational therapist or physiotherapist) who assessed the client at home
- Issued by
- Alberta Aids to Daily Living (AADL)
- Format
- Fillable PDF
- Language
- English
- AADL13196
Eligibility Summary for Pediatric Standing Frames
Summarizes the authorizer's assessment of impairments, environment, trial, transfers and standing plan, and must be uploaded with every pediatric standing frame authorization.
- Completed by
- AADL authorizer (occupational therapist, physiotherapist or registered nurse); parent signs
- Issued by
- Alberta Aids to Daily Living (AADL)
- Format
- Fillable PDF
- Language
- English
- AHC2176
Out-of-Country Health Services application form
Requests provincial funding for insured health services that cannot be had within Canada, and a patient is not allowed to make the referral themselves.
- Completed by
- Licensed Alberta physician or dentist (patients cannot self-refer)
- Issued by
- Alberta Health – Out-of-Country Health Services Committee
- Language
- English
Other forms
-
Standard Invoice
Itemizes service costs so a practitioner can be paid or reimbursed under Care-First.
- Completed by
- Health care practitioner
- Issued by
- Alberta Treasury Board and Finance (Care-First)
- Language
- English
Saskatchewan
Lab and imaging requisitions
-
Saskatchewan Health Authority's requisition for hereditary cancer and endocrine gene panels at the Roy Romanow Provincial Laboratory. The ordering physician or genetic counsellor completes it and signs the consent attestation.
- Completed by
- Ordering physician or genetic counsellor
- Issued by
- Saskatchewan Health Authority, Roy Romanow Provincial Laboratory
- Format
- Fillable PDF
- Language
- English
Workers' compensation
-
WCB Saskatchewan's first report from the primary practitioner on a work injury. The treating physician completes all of it.
- Completed by
- Treating physician (primary practitioner)
- Issued by
- Saskatchewan Workers' Compensation Board
- Format
- Fillable PDF
- Language
- English
-
WCB Saskatchewan's follow-up report from the treating physician on a work injury, used for progress and at discharge. The physician completes all of it.
- Completed by
- Treating physician (primary practitioner)
- Issued by
- Saskatchewan Workers' Compensation Board
- Format
- Fillable PDF
- Language
- English
- CHI
Chiropractor's Initial Report (CHI)
A chiropractor's report of initial findings, which has to be sent in the first three days after treatment begins.
- Completed by
- Chiropractor
- Issued by
- WCB Saskatchewan
- Format
- Fillable PDF
- Language
- English
- CHP
Chiropractor's Progress/Discharge Report (CHP)
Updates the board after each block of six chiropractic treatments, or reports discharge.
- Completed by
- Chiropractor
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- M7
Dentist's Initial Report (M7)
Reports a work-related dental injury to the Saskatchewan board, together with the dentist's proposed treatment plan.
- Completed by
- Dentist
- Issued by
- WCB Saskatchewan
- Format
- Fillable PDF
- Language
- English
-
Functional examination record
Records the results of a functional examination of an injured worker for the Saskatchewan board.
- Completed by
- Treating practitioner
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- MCARE
Hearing loss – Request for funding (MCARE)
Asks the board to fund hearing services or hearing aids for a worker with a hearing loss claim.
- Completed by
- Hearing service provider (audiologist / hearing instrument practitioner)
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- CR
International health care provider report (CR)
Lets a provider outside Canada report on progress for a worker injured in Saskatchewan.
- Completed by
- Health care provider outside Canada
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
-
Notification of Intake for Secondary or Tertiary Treatment Program
Tells the board that a worker has been admitted to a secondary or tertiary treatment program.
- Completed by
- Accredited secondary/tertiary treatment program clinician
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- OTI
Occupational Therapist's Initial Report (OTI)
Gives the occupational therapist's first assessment of an injured worker to the Saskatchewan board at the start of treatment.
- Completed by
- Occupational therapist
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- OTP
Occupational Therapist's Progress/Discharge Report (OTP)
Updates the board on an injured worker's occupational therapy, or reports discharge.
- Completed by
- Occupational therapist
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- PTI
Physiotherapist's Initial Report (PTI)
Gives the physiotherapist's first assessment of an injured worker to the Saskatchewan board at the start of treatment.
- Completed by
- Physiotherapist
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- PTP
Physiotherapist's Progress/Discharge Report (PTP)
Updates the board on an injured worker's physiotherapy as it progresses, or reports that the worker has been discharged.
- Completed by
- Physiotherapist
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- TXD
Practitioner's Discharge Summary (TXD)
Closes out treatment with a discharge summary from an accredited practitioner whose discipline has no dedicated form.
- Completed by
- Other accredited practitioners
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- TXI
Practitioner's Initial Assessment (TXI)
Gives the first assessment from an accredited practitioner whose discipline has no dedicated form.
- Completed by
- Other accredited practitioners
- Issued by
- WCB Saskatchewan
- Format
- Fillable PDF
- Language
- English
- TXP
Practitioner's Progress Report (TXP)
Updates the board on treatment from an accredited practitioner whose discipline has no dedicated form.
- Completed by
- Other accredited practitioners
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- PRTW
Practitioner's Return-to-Work (PRTW) Report
Confirms a return-to-work plan that has been agreed on, including hours and restrictions, with copies going to the primary care provider, the employer and the worker.
- Completed by
- Treating practitioner (physician or other primary practitioner)
- Issued by
- WCB Saskatchewan
- Format
- Fillable PDF
- Language
- English
- MCARE
Primary Level Authorization to Treat – Massage Therapy (MCARE)
Requests authorization for a massage therapist to begin primary-level treatment of a worker.
- Completed by
- Massage therapist
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- MCARE
Primary Level Authorization to Treat – Mental Health and Occupational Therapy (MCARE)
Requests authorization for a mental health provider or occupational therapist to begin primary-level treatment of a worker.
- Completed by
- Psychologist/mental health provider or occupational therapist
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
- PSYI
Psychology - Initial Assessment (PSYI)
Gives the psychologist's first assessment of an injured worker, including DSM-5 diagnoses and a treatment plan.
- Completed by
- Psychologist
- Issued by
- WCB Saskatchewan
- Format
- Fillable PDF
- Language
- English
- PSYP
Psychology Progress/Discharge Report (PSYP)
Updates the board on an injured worker's psychological treatment, or reports discharge.
- Completed by
- Psychologist
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
Insurance claims
-
Saskatchewan Blue Cross's physician statement for a critical illness insurance claim. The patient signs the Patient Authorization and the attending physician completes the statement.
- Completed by
- Patient (Patient Authorization); attending physician (statement)
- Issued by
- Saskatchewan Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Attending Physician's Initial Statement Form
Supports the first application of a Saskatchewan health-care worker to the Disability Income Plan, across the SEIU-West, SUN, CUPE and General plans.
- Completed by
- Licensed physician or nurse practitioner; a chiropractor or registered psychologist may complete it for up to eight weeks from the disability start date
- Issued by
- 3sHealth (Disability Income Plan)
- Format
- Fillable PDF
- Language
- English
-
Initial Disability Insurance Medical Statement
Opens a disability claim using the standard industry medical statement completed by the attending physician or another provider.
- Completed by
- Attending physician or other medical provider
- Issued by
- Saskatchewan Blue Cross
- Format
- Language
- English
-
Permanent Impairment Description form
Describes a customer's scarring by location, type, length and width, so SGI can assess a permanent impairment benefit.
- Completed by
- Customer's practitioner
- Issued by
- SGI
- Format
- Sent for each case
- Language
- English
- DISB-1006
Proof of Death Physicians Statement
Gives the physician's proof of death for life and accidental death claims.
- Completed by
- Attending physician
- Issued by
- Saskatchewan Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Range of Motion Charts
A physiotherapist or occupational therapist records measurements of active joint movement that SGI uses when it assesses permanent impairment.
- Completed by
- Physiotherapist or occupational therapist (customer's choice)
- Issued by
- SGI
- Format
- Sent for each case
- Language
- English
Government benefits and tax credits
-
Saskatchewan Student Aid's form for confirming a student's disability for loans and disability grants. A physician or other qualified practitioner completes it.
- Completed by
- Physician or other qualified practitioner
- Issued by
- Saskatchewan Ministry of Advanced Education, Student Service Centre
- Format
- Fillable PDF
- Language
- English
Drug coverage
-
Saskatchewan Blue Cross's request for coverage of a drug that needs special authorization. The member completes page 1 and the prescribing physician completes the drug detail and physician statement.
- Completed by
- Plan member or patient (page 1); prescribing physician (specialty drug detail and physician statement)
- Issued by
- Saskatchewan Blue Cross
- Format
- Fillable PDF
- Language
- English
- CLMS 1007
Chronic Weight Management Prescription Drug Special Authorization Request
Requests group plan coverage of a chronic weight management drug (Zepbound, Wegovy, Saxenda, Contrave or Xenical); the member completes the first page.
- Completed by
- Physician (member/patient completes page 1)
- Issued by
- Saskatchewan Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Request for Exception Drug Status (EDS)
Requests Saskatchewan Drug Plan coverage for a specific patient's drug that carries exception criteria, including renewals; patients and families cannot submit it themselves.
- Completed by
- Physician, nurse practitioner or pharmacist (individuals and families cannot request)
- Issued by
- Saskatchewan Drug Plan and Extended Benefits Branch
- Format
- Online only
- Language
- English
Driving and licensing
- 3167
Commercial Driver's Licence Medical Report
Documents the medical needed before testing for Class 1 to 4 licences and some Class 5 endorsements, repeated every five, three or one year depending on age.
- Completed by
- Physician, NP or occupational health nurse
- Issued by
- SGI
- Format
- Language
- English
-
Confidential Reporting Form - Private Citizen
Asks the medical review unit to review someone's medical fitness to drive, and is accepted from medical practitioners and medical offices as well as private citizens.
- Completed by
- Any reporter; SGI accepts it from medical practitioners and medical offices
- Issued by
- SGI
- Format
- Language
- English
Mental health and medico-legal
-
The second psychiatrist's certificate under section 24.4 of Saskatchewan's Mental Health Services Act that validates a community treatment order. A psychiatrist other than the one who issued the order completes it.
- Completed by
- A psychiatrist other than the one who issued the order, or a physician designated by the regional director
- Issued by
- Saskatchewan Ministry of Health
- Format
- Fillable PDF
- Language
- English
- Form G
Certificate of Medical Practitioner for Compulsory Admission of a Person to a Mental Health Centre
The section 24 certificate for involuntary admission under Saskatchewan's Mental Health Services Act. A physician with admitting privileges, or a supervised psychiatry resident, completes it and signs in front of a witness.
- Completed by
- Physician with admitting privileges to a mental health centre, or a supervised resident in psychiatry
- Issued by
- Saskatchewan Ministry of Health
- Format
- Fillable PDF
- Language
- English
- Form A
Certificate of Physician or Prescribed Health Professional that Psychiatric Examination is Required
The section 18 certificate under Saskatchewan's Mental Health Services Act. The examining physician or prescribed health professional completes and signs it in front of a witness.
- Completed by
- Examining physician or prescribed health professional
- Issued by
- Saskatchewan Ministry of Health
- Format
- Fillable PDF
- Language
- English
- Form A
Form A - Certificate of Physician or Prescribed Health Professional that Psychiatric Examination is Required
Certifies that a person refusing examination appears to have a mental disorder and should be examined, authorizing apprehension and transport to a physician with admitting rights.
- Completed by
- Examining physician, or a prescribed health professional (supervised psychiatry resident or qualifying rural RN, RPN or NP) when no physician is available within a reasonable period
- Issued by
- Saskatchewan Ministry of Health (Mental Health Services Act forms)
- Format
- Fillable PDF
- Language
- English
- Form G
Form G - Certificate of Medical Practitioner for Compulsory Admission of a Person to a Mental Health Centre
Supports compulsory admission to a mental health centre; two certificates, at least one from a psychiatrist, allow detention through day 21, renewable in further 21-day periods.
- Completed by
- Physician with admitting privileges to a mental health centre, or a resident in psychiatry supervised by such a psychiatrist (two certificates, at least one by a psychiatrist)
- Issued by
- Saskatchewan Ministry of Health (Mental Health Services Act forms)
- Format
- Fillable PDF
- Language
- English
- Form H.3
Form H.3 - Community Treatment Order
Orders community-based treatment in place of hospital stay for a patient, listing the criteria met, services, residence if required and a term of up to six months.
- Completed by
- Examining psychiatrist
- Issued by
- Saskatchewan Ministry of Health (Mental Health Services Act forms)
- Format
- Fillable PDF
- Language
- English
- Form H.4
Form H.4 - Certificate in Support of a Community Treatment Order
Adds a second psychiatrist's agreement to a community treatment order, which the order needs before it takes effect.
- Completed by
- A psychiatrist other than the one who issued the order (or a physician designated by the regional director under s.24.31 when no other psychiatrist is reasonably available)
- Issued by
- Saskatchewan Ministry of Health (Mental Health Services Act forms)
- Format
- Fillable PDF
- Language
- English
Parking, transit and travel
-
Access Transit Application Form - Part B
Records a practitioner's assessment of whether a patient can functionally use regular Saskatoon buses, as the external half of the Access Transit paratransit application.
- Completed by
- RN, NP, RPN, LPN, OT, PT, rehabilitation therapist, optometrist or physician familiar with the applicant's disability
- Issued by
- Saskatoon Transit (City of Saskatoon)
- Format
- Language
- English
-
Accessible Parking Program application (individual)
Used to request or renew an accessible parking permit in Saskatchewan for patients who cannot walk 50 metres without help unless they accept great difficulty or danger.
- Completed by
- Physician, NP, occupational therapist, physical therapist or chiropractor
- Issued by
- SaskAbilities
- Format
- Language
- English
Health programs
-
Pediatric Out-of-Province Travel Assistance Program (PTAP) Specialist Application
Requests prior approval of travel assistance for a child who has to leave Saskatchewan for medically required treatment unavailable in the province.
- Completed by
- Referring Saskatchewan-licensed specialist
- Issued by
- Saskatchewan Ministry of Health / Saskatchewan Health Authority
- Format
- Fillable PDF
- Language
- English
-
Prior Approval Request: Abdominal Panniculectomy (354N)
Requests prior approval from the Ministry of Health so panniculectomy of the abdomen (fee code 354N) is insured, with the four Section N criteria documented.
- Completed by
- Saskatchewan specialist who will perform the surgery (only that specialist may complete it)
- Issued by
- Saskatchewan Ministry of Health – Medical Services Branch
- Format
- Language
- English
-
Saskatchewan Insulin Pump Program Application Form
Applies for insulin pump coverage for an adult with type 1 diabetes through the Saskatchewan Insulin Pump Program.
- Completed by
- SHA diabetes education program or an authorized diabetes specialist physician
- Issued by
- Saskatchewan Ministry of Health – SAIL
- Language
- English
-
Saskatchewan Insulin Pump Program Pediatric Application Form
Applies for insulin pump coverage for a patient under 18 with type 1 diabetes through the Saskatchewan Insulin Pump Program.
- Completed by
- SHA pediatric diabetes education program or an authorized pediatric diabetes specialist physician
- Issued by
- Saskatchewan Ministry of Health – SAIL
- Language
- English
-
SK CDM-QIP Diabetes Flow Sheet
Tracks the best-practice indicators for adults with diabetes at each chronic disease management visit, which feed the annual quality improvement payment.
- Completed by
- Family physician (or clinic care team) at each chronic disease management visit
- Issued by
- Saskatchewan Ministry of Health (CDM-QIP)
- Format
- Language
- English
-
Therapeutic Nutritional Products Program Application
Applies for SAIL's program that helps with prescribed nutrition products based on income, completed by a dietitian.
- Completed by
- Dietitian
- Issued by
- Saskatchewan Ministry of Health – SAIL
- Format
- Language
- English
Manitoba
Lab and imaging requisitions
- R250-10-115
CT Request Form
Shared Health's standardized requisition for every urgent and elective CT exam in Manitoba. The ordering clinician completes and signs it.
- Completed by
- Ordering clinician
- Issued by
- Shared Health Manitoba, Diagnostic Services
- Format
- Fillable PDF
- Language
- English
- R250-10-116
Request for DI Examination (Rural)
Shared Health's requisition for X-ray, ultrasound and nuclear medicine exams at imaging sites outside Winnipeg. The ordering clinician completes and signs it.
- Completed by
- Ordering clinician
- Issued by
- Shared Health Manitoba, Diagnostic Services
- Format
- Fillable PDF
- Language
- English
- R250-10-94
Biochemistry / Hematology Requisition - Clinic & Community, Winnipeg and Brandon
Orders routine blood chemistry, hematology and drug monitoring from a clinic or community site in Winnipeg or Brandon, which has its own version of the requisition.
- Completed by
- Ordering provider; collector completes collection fields
- Issued by
- Shared Health Manitoba (Diagnostic Services)
- Format
- Fillable PDF
- Language
- English
- R250-10-92
Biochemistry / Hematology Requisition - Clinics & Community, Outside Winnipeg and Brandon
Orders routine blood chemistry, hematology, drug levels and simple urine or point-of-care tests from a clinic or community site outside Winnipeg and Brandon.
- Completed by
- Ordering provider; collector completes collection fields
- Issued by
- Shared Health Manitoba (Diagnostic Services)
- Format
- Fillable PDF
- Language
- English
- R250-10-115
CT Request Form
Orders a CT scan in Manitoba, whether urgent or elective and whether the patient is an outpatient, in emergency or admitted.
- Completed by
- Ordering clinician
- Issued by
- Shared Health Manitoba (Diagnostic Services)
- Format
- Language
- English
- R130-80-04
MRI Request Form
Orders an MRI in Manitoba, with safety screening questions, kidney function questions for IV contrast and prompts for children who may need sedation.
- Completed by
- Referring clinician
- Issued by
- Shared Health Manitoba (Diagnostic Services)
- Format
- Language
- English
Workers' compensation
- Form 4
Doctor First Report
WCB Manitoba's report from the physician who first sees a worker for a workplace injury. The physician completes and signs every section.
- Completed by
- Physician
- Issued by
- Workers Compensation Board of Manitoba
- Format
- Fillable PDF
- Language
- English
- Form 7
Doctor Progress Report
WCB Manitoba's report for follow-up visits on an open claim. The treating physician completes and signs it.
- Completed by
- Treating physician
- Issued by
- Workers Compensation Board of Manitoba
- Format
- Fillable PDF
- Language
- English
-
WCB Manitoba's report for starting a worker on opioids past the acute phase of an injury. The prescribing physician completes and signs it.
- Completed by
- Prescribing physician
- Issued by
- Workers Compensation Board of Manitoba
- Format
- Fillable PDF
- Language
- English
-
WCB Manitoba's follow-up report for a worker taking opioids on a claim. The prescribing physician completes and signs it.
- Completed by
- Prescribing physician
- Issued by
- Workers Compensation Board of Manitoba
- Format
- Fillable PDF
- Language
- English
-
Athletic therapy initial and progress/discharge reports (eHealth Portal)
Lets an athletic therapist report on a worker's injury at the start of care and again at follow-up or discharge, filed through the board's online portal.
- Completed by
- Athletic therapist
- Issued by
- WCB Manitoba
- Format
- Online only
- Language
- English
- 4C
Chiropractor First Report
Premier rapport du chiropraticien
Reports a worker's injury at the first chiropractic visit, with objective findings, the treatment plan and what work the patient can do.
- Completed by
- Chiropractor
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
- 7C
Chiropractor Progress Report
Rapport du chiropraticien sur l’évolution du patient
Updates the board on a worker's chiropractic care at follow-up visits or at discharge.
- Completed by
- Chiropractor
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
-
Dentist Report
Rapport du dentiste
Describes a dental injury from work, with treatment so far, a tooth chart, the plan going forward and a cost estimate for the board.
- Completed by
- Dentist
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
-
Doctor First Report
Premier rapport du médecin
Reports a worker's workplace injury to the compensation board after the first visit, including whether modified work is possible and any restrictions.
- Completed by
- Physician (optometrists also bill this report under code 3024)
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
-
Doctor Progress Report
Rapport du médecin sur l’évolution du patient
Updates the board on how a worker is recovering and what work they can handle, at follow-up visits or when care ends.
- Completed by
- Physician (optometrists bill code 3025)
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
- OMIR
Initial - Opioid Management Report
Formulaire de rapport initial de gestion des opioïdes
Tells the board why a worker on a compensation claim is starting opioids and how the prescriber plans to manage them.
- Completed by
- Physician or nurse practitioner
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
-
Opioid treatment agreement
Entente de traitement aux opioïdes
Sets out the terms between a prescriber and a worker on a compensation claim who is being treated with opioids, signed by both.
- Completed by
- Prescribing physician/NP and worker
- Issued by
- WCB Manitoba
- Format
- Language
- English
-
Physiotherapy application for additional treatment
Demande de traitement additionnel – Physiothérapeute
Asks the board to approve more physiotherapy visits once the sessions already authorized for a worker have run out.
- Completed by
- Physiotherapist
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
- PRI
Physiotherapy Initial Report
Rapport initial de physiothérapie
Gives the board a physiotherapist's first assessment of an injured worker before treatment gets under way.
- Completed by
- Physiotherapist
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
- PPDA
Physiotherapy Progress/ Discharge Assessment
Rapport sur l’évolution/la fin de la prise en charge du patient en physiothérapie
Reports a worker's physiotherapy progress during treatment or their status at discharge, for the compensation board.
- Completed by
- Physiotherapist
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
- OMPR
Progress - Opioid Management Report
Rapport sur l’évolution de la gestion des opioïdes
Follows up on a worker's opioid therapy for the board, reporting how treatment is going after the initial opioid report.
- Completed by
- Physician or nurse practitioner
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
Insurance claims
-
Manitoba Blue Cross's physician report for a trip cancellation claim. The attending physician completes the report about the illness or injury that caused the cancellation.
- Completed by
- Attending physician
- Issued by
- Manitoba Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Manitoba Public Insurance's first report from the treating practitioner after a motor vehicle collision. The practitioner completes the report and the patient or guardian signs the authorization to release it.
- Completed by
- Treating practitioner; patient or guardian signs the authorization
- Issued by
- Manitoba Public Insurance
- Format
- Fillable PDF
- Language
- English
-
Assisted Care/Nursing Recommendation Form
Recommends assisted care or private nursing so the insurer can pay the related claim.
- Completed by
- Attending physician or nursing service
- Issued by
- Manitoba Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Attending Physician’s Statement – Application for Critical Condition Benefit
Provides the physician's statement behind an application for the critical condition benefit.
- Completed by
- Attending physician
- Issued by
- Manitoba Blue Cross
- Format
- Language
- English
-
Attending Physicians Report
Supports a trip cancellation claim with the diagnosis, the first visit, any hospital stay, and whether the condition prevented travel.
- Completed by
- Attending physician
- Issued by
- Manitoba Blue Cross
- Format
- Fillable PDF
- Language
- English
- 18-019-416
Chiropractic Report
Reports a chiropractor's findings on an injured claimant, including a work-capacity assessment and the patient's authorization.
- Completed by
- Chiropractor
- Issued by
- MPI
- Format
- Fillable PDF
- Language
- English
-
Initial Disability Insurance Medical Statement
Opens a disability benefit claim using the standard industry medical statement completed by the attending physician.
- Completed by
- Attending physician or other medical provider
- Issued by
- Manitoba Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Initial Therapy Report
For a newly injured claimant under Manitoba's personal injury protection plan, reports symptoms, signs, outcome measures, the diagnosis, injury category and work status.
- Completed by
- Physiotherapist or athletic therapist
- Issued by
- MPI
- Format
- Fillable PDF
- Language
- English and French
-
Orthotics, Orthopedic Shoes, and Modifications Claim Form
Asks for pre-authorization or payment for custom orthotics and for orthopedic shoes or shoe modifications, completed by the pedorthist or orthotist who supplies them.
- Completed by
- Dispensing professional (e.g., pedorthist or orthotist); prescriber is named
- Issued by
- Manitoba Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Subsequent Therapy Report
Follows up on a claimant's response to treatment and current status under Manitoba's personal injury protection plan.
- Completed by
- Physiotherapist or athletic therapist
- Issued by
- MPI
- Format
- Fillable PDF
- Language
- English and French
-
Therapy Discharge Report
Closes out a claimant's therapy when treatment funded by Manitoba's personal injury protection plan ends.
- Completed by
- Physiotherapist or athletic therapist
- Issued by
- MPI
- Format
- Fillable PDF
- Language
- English
Government benefits and tax credits
-
Medical Equipment Request and Justification
Asks for medical equipment and devices for income assistance and children's or community living disability services clients, with separate sections for prescriber and assessors.
- Completed by
- Section 2: regulated health professional (prescriber); Section 3a: any regulated health professional; Section 3b (specialized equipment): OT, PT, respiratory therapist or SLP
- Issued by
- Manitoba Families – Disability and Health Supports Unit
- Format
- Fillable PDF
- Language
- English
-
Medical Supply Request and Justification Form
Asks for medical supplies for people supported by income assistance or the children's and community living disability programs, with the health professional's justification.
- Completed by
- Health professional: physician, registered dietitian, registered physician assistant, registered nurse practitioner, LPN, RN, registered midwife, OT, PT, respiratory therapist or speech language therapist
- Issued by
- Manitoba Families – Disability and Health Supports Unit
- Format
- Language
- English
-
Therapeutic Diet and Nutrition Supplement Request and Justification Form
Asks for a diet allowance or nutritional supplements for clients on income assistance or disability services, with approval for no more than 12 months.
- Completed by
- Health professional: physician, registered dietitian, registered physician assistant, registered nurse practitioner, LPN, RN, registered midwife, OT, PT, respiratory therapist or speech language therapist
- Issued by
- Manitoba Families – Disability and Health Supports Unit
- Format
- Fillable PDF
- Language
- English
-
Verification of Disability Form
Formulaire Vérification de l'invalidité
Confirms a student's lasting or prolonged disability and functional limits to unlock Canada student grants, including funding for services and equipment.
- Completed by
- Qualified registered medical assessor licensed where the assessment is done (e.g., physician, nurse practitioner, audiologist or psychologist)
- Issued by
- Manitoba Student Aid
- Format
- Language
- English and French
-
Wheelchair Seating Component Request and Justification Form
Orders wheelchair seating components from the Materials Distribution Agency for disability and health supports clients, typically after an OT or PT assessment.
- Completed by
- Health professional (typically OT or PT; see the form guide)
- Issued by
- Manitoba Families – Disability and Health Supports Unit
- Format
- Language
- English
Drug coverage
-
Manitoba Health's general request for Exception Drug Status coverage of a drug under Pharmacare and the provincial drug programs. The prescriber completes and signs the whole form.
- Completed by
- Prescriber
- Issued by
- Manitoba Health, Seniors and Long-Term Care
- Format
- Fillable PDF
- Language
- English
-
Manitoba Health's Exception Drug Status request for canagliflozin, empagliflozin, linagliptin, saxagliptin, and sitagliptin. The prescriber completes and signs the whole form.
- Completed by
- Prescriber
- Issued by
- Manitoba Health, Seniors and Long-Term Care
- Format
- Fillable PDF
- Language
- English
-
Continuous Glucose Monitor (CGM) / Flash Glucose Monitor (FGM) Special Authorization Request
Requests coverage of continuous or flash glucose monitoring through Manitoba Blue Cross special authorization.
- Completed by
- Prescribing physician
- Issued by
- Manitoba Blue Cross
- Format
- Fillable PDF
- Language
- English
-
Drug-specific Exception Drug Status request forms
Groups the Manitoba exception drug status forms written for particular drugs and classes, such as migraine agents, biologics, heart failure drugs and MS treatments.
- Completed by
- Prescriber (physician or NP; some require specialists)
- Issued by
- Manitoba Pharmacare (Manitoba Health)
- Format
- Language
- English
-
Exception Drug Status (EDS) Request Form
Asks Manitoba Pharmacare to cover a Part 3 drug under exception status when no drug-specific form exists for it.
- Completed by
- Prescriber (physician or nurse practitioner; provides licence number)
- Issued by
- Manitoba Pharmacare (Manitoba Health)
- Format
- Fillable PDF
- Language
- English
-
Oral Anti-Diabetic Medications (EDS request form)
Requests exception drug status coverage in Manitoba for an oral diabetes medication, using the form written specifically for that drug group.
- Completed by
- Prescriber (physician or nurse practitioner)
- Issued by
- Manitoba Pharmacare (Manitoba Health)
- Format
- Language
- English
Driving and licensing
- MG-3979
Medical Examination Report Concerning a Person's Fitness to Drive a Motor Vehicle
Assesses whether someone is medically fit to drive, requested by the driver fitness office for class applicants, recalls, suspensions or review committee matters.
- Completed by
- Physician
- Issued by
- MPI
- Format
- Language
- English
- MG-3890
Report of Visual Examination (Ophthalmologist/Optometrist)
Reports vision findings when driver fitness requests them for a recall, second opinion, review committee, class applicant, failed standard or suspension.
- Completed by
- Ophthalmologist or optometrist
- Issued by
- MPI
- Format
- Language
- English
- MCA-Form-157-2021
Report to Registrar of Motor Vehicles
Reports an illness or disability that could interfere with safe driving, a duty the law places on physicians and optometrists, and starts a driver fitness review.
- Completed by
- Physician or optometrist
- Issued by
- MPI
- Format
- Fillable PDF
- Language
- English
Mental health and medico-legal
- Form 4
Form 4 - Application for Involuntary Psychiatric Assessment
Formule 4 - Demande d'évaluation psychiatrique obligatoire
An application to the medical director of a facility for a psychiatrist to assess a person against their will, authorizing custody, transport and detention for up to 72 hours.
- Completed by
- Qualified health professional: a physician, or a physician assistant or clinical assistant authorized under the CPSM General Regulation (M.R. 163/2018)
- Issued by
- Manitoba Health (Mental Health Act forms)
- Format
- Language
- Bilingual
- Form 5
Form 5 - Application by Attending Physician for Change of Patient's Status from Voluntary to Involuntary
Formule 5 - Demande visant le placement en cure obligatoire d'un malade en cure volontaire
Changes a voluntary patient to involuntary status, which triggers a psychiatrist's review within 72 hours, or within 24 hours if the person has already been in hospital longer than 72.
- Completed by
- Attending physician of the voluntary patient
- Issued by
- Manitoba Health (Mental Health Act forms)
- Format
- Language
- Bilingual
- Form 6
Form 6 - Involuntary Admission Certificate
Formule 6 - Certificat d'admission en cure obligatoire
Admits a person as an involuntary psychiatric patient after assessment, allowing detention, restraint, observation, examination and treatment for up to 21 days.
- Completed by
- Examining psychiatrist (not the psychiatrist who applied for the assessment)
- Issued by
- Manitoba Health (Mental Health Act forms)
- Format
- Language
- Bilingual
- Form 7
Form 7 - Renewal Certificate
Formule 7 - Certificat de renouvellement
Extends an involuntary patient's status by up to three months at a time, completed by the attending psychiatrist.
- Completed by
- Attending psychiatrist of the involuntary patient
- Issued by
- Manitoba Health (Mental Health Act forms)
- Format
- Language
- Bilingual
Parking, transit and travel
-
Parking Permit Program application
Starts an accessible parking permit application for a physically disabled patient, covering temporary permits of 3 to 36 months or permanent ones, for a vehicle or motorcycle.
- Completed by
- Physician, clinic-based NP, chiropractor, occupational therapist or physiotherapist
- Issued by
- Manitoba Possible
- Format
- Fillable PDF
- Language
- English and French
Ontario
Lab and imaging requisitions
- ONPSC 305 A
Cancer Care Ontario CEA Assay Requisition Form
Dynacare's authorization form for a carcinoembryonic antigen test in Ontario. The ordering clinician ticks the Cancer Care Ontario criterion that applies and signs.
- Completed by
- Ordering clinician
- Issued by
- Dynacare (Ontario Patient Services)
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' requisition for a carcinoembryonic antigen test in Ontario. The ordering provider chooses funded or non-funded testing and, for funded testing, the reason and the date of the last CEA.
- Completed by
- Ordering healthcare provider
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' Ontario requisition for Holter monitoring and 24-hour ambulatory blood pressure monitoring. The ordering clinician completes and signs it, and the patient brings it to the hook-up appointment.
- Completed by
- Ordering healthcare provider
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
- F-SD-SCG-4000
COVID-19 and Respiratory Virus Test Requisition
Public Health Ontario's former requisition for COVID-19 and respiratory virus testing, still linked from LifeLabs. PHO stopped accepting it on January 5, 2026, and respiratory testing now goes on PHO's General Test Requisition.
- Completed by
- Ordering clinician
- Issued by
- Public Health Ontario
- Format
- Fillable PDF
- Language
- English
-
Dynacare's requisition for skin biopsies sent for dermatopathology in Ontario. The requisitioning clinician completes and signs it; the lab fills in the gross description and billing codes.
- Completed by
- Requisitioning clinician or practitioner
- Issued by
- Dynacare
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' Ontario requisition for skin biopsies and excisions sent for dermatopathology. The clinician who did the procedure completes and signs it.
- Completed by
- Requesting clinician or practitioner
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
-
Ontario Health's requisition for a ColonCancerCheck FIT kit mailed to an eligible, asymptomatic patient. A physician or nurse practitioner completes and signs it.
- Completed by
- Physician or nurse practitioner
- Issued by
- Ontario Health (Cancer Care Ontario), ColonCancerCheck
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' copy of the Ontario laboratory requisition with the tests for a FIB-4 liver fibrosis score already selected. The ordering clinician completes the rest and signs it.
- Completed by
- Ordering clinician
- Issued by
- LifeLabs (Ontario Ministry of Health requisition 4422-84)
- Format
- Fillable PDF
- Language
- English
-
Dynacare's Ontario requisition for flow cytometry, from HLA-B27 and CD4/CD8 counts to lymphoproliferative and leukemia panels. The ordering provider completes it and attaches it to the Ministry of Health lab requisition.
- Completed by
- Ordering healthcare provider
- Issued by
- Dynacare
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' Ontario requisition for gastrointestinal biopsies and specimens, usually from endoscopy. The clinician who took the specimens completes and signs it.
- Completed by
- Requesting clinician or practitioner
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
- F-SD-SCG-1000
General Test Requisition
Public Health Ontario Laboratory's requisition for most tests it performs, apart from HIV and culture isolates. The ordering health care provider completes all of it.
- Completed by
- Ordering health care provider authorized to order laboratory tests in Ontario
- Issued by
- Public Health Ontario
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' Ontario requisition for private-pay HPV and cervical cytology for patients outside the Ontario Cervical Screening Program. The clinician orders the test, and both clinician and patient sign the payment acknowledgement.
- Completed by
- Requesting clinician; patient signs the payment acknowledgement
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' Ontario requisition for gynecologic tissue such as endometrial and cervical biopsies. The clinician who took the specimens completes and signs it.
- Completed by
- Requesting clinician or practitioner
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
-
Public Health Ontario's requisition for HCV RNA and HBV DNA viral load, genotyping and drug resistance testing. The ordering clinician completes the whole form.
- Completed by
- Ordering health care provider
- Issued by
- Public Health Ontario
- Format
- Fillable PDF
- Language
- English
-
Ontario's referral for annual high-risk breast screening with mammography and MRI. The referring family doctor or nurse practitioner completes and signs it and faxes it to a High Risk OBSP site.
- Completed by
- Referring family doctor or nurse practitioner
- Issued by
- Ontario Health (Cancer Care Ontario)
- Format
- Fillable PDF
- Language
- English
-
Dynacare's requisition for biopsy tissue sent for histopathology in Ontario. The requisitioning clinician completes and signs it, and lists each shipment on the attached specimen tracking log.
- Completed by
- Requisitioning clinician or practitioner
- Issued by
- Dynacare
- Format
- Fillable PDF
- Language
- English
- F-SD-SCG-1001
HIV Serology & PCR Test Requisition
Public Health Ontario's requisition for HIV diagnostic serology and HIV-1/-2 PCR. The ordering clinician completes the whole form.
- Completed by
- Ordering health care provider
- Issued by
- Public Health Ontario
- Format
- Fillable PDF
- Language
- English
-
Public Health Ontario's requisition for HIV-1 resistance genotyping, CCR5 tropism and HLA-B*57:01 testing. The ordering clinician completes the whole form.
- Completed by
- Ordering health care provider
- Issued by
- Public Health Ontario
- Format
- Fillable PDF
- Language
- English
-
The Ontario Cervical Screening Program requisition colposcopists use to order HPV and cytology tests while following up abnormal screening results. The colposcopist completes all of it.
- Completed by
- Colposcopist
- Issued by
- Ontario Health (Ontario Cervical Screening Program)
- Format
- Fillable PDF
- Language
- English (French on request from Ontario Health)
-
The Ontario Cervical Screening Program requisition for ordering a screening HPV test, with reflex cytology when positive, or cytology alone in one follow-up case. The physician, nurse practitioner or midwife completes all of it.
- Completed by
- Physician, nurse practitioner or midwife
- Issued by
- Ontario Health (Ontario Cervical Screening Program)
- Format
- Fillable PDF
- Language
- English (French on request from Ontario Health)
-
LifeLabs' copy of the Ontario laboratory requisition set up to order the Klinrisk panel, which predicts chronic kidney disease progression. The ordering clinician completes and signs it.
- Completed by
- Ordering clinician
- Issued by
- LifeLabs (Ontario Ministry of Health requisition 4422-84)
- Format
- Fillable PDF
- Language
- English
- 4422-84
Laboratory Requisition
Ontario's standard requisition for community laboratory tests. The requisitioning clinician or practitioner completes and signs it, and the laboratory records the specimen collection.
- Completed by
- Requisitioning clinician or practitioner
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English
-
Dynacare's requisition for Ministry of Health funded Harmony cell-free DNA screening in Ontario, with an attached eligibility form. The prescriber completes the requisition and Category I; Category II must come from a genetics or maternal fetal medicine specialist.
- Completed by
- Prescriber (requisition and Category I); genetics or MFM specialist (Category II)
- Issued by
- Dynacare
- Format
- Fillable PDF
- Language
- English
- F-SD-SCG-1009
Newborn CMV PCR Test Requisition
Public Health Ontario's requisition to confirm a CMV DNA result from the newborn screen with a urine CMV PCR. The ordering physician completes the whole form.
- Completed by
- Ordering physician
- Issued by
- Public Health Ontario
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' Ontario requisition for cytology on specimens other than cervical and vaginal samples, such as urine, sputum, body fluids and fine needle aspirates. The ordering clinician completes it.
- Completed by
- Requesting clinician or practitioner
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
-
Dynacare's requisition for non-gynecological cytology in Ontario, such as urine, fine needle aspirates, body fluids and sputum. The requisitioning clinician completes and signs it.
- Completed by
- Requisitioning clinician or practitioner (physician or nurse practitioner)
- Issued by
- Dynacare
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' private-pay requisition for blood-based Alzheimer's disease tests in Ontario. An authorized ordering practitioner ticks the tests and signs.
- Completed by
- Authorized ordering healthcare practitioner
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
- F-SD-SCG-1002
Prenatal Screening Requisition
Public Health Ontario's requisition for routine prenatal serology: hepatitis B surface antigen, rubella, syphilis and HIV. The clinician completes the whole form.
- Completed by
- Ordering clinician
- Issued by
- Public Health Ontario
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' Ontario requisition for OHIP-funded Panorama NIPT, with the Prenatal Screening Ontario eligibility checklist attached. The ordering provider completes it, a specialist completes Category II when needed, and the patient signs the consent.
- Completed by
- Ordering provider; Genetics or MFM specialist (Category II); patient signs the consent
- Issued by
- LifeLabs Genetics
- Format
- Fillable PDF
- Language
- English and French
-
Dynacare's requisition for a Holter study using Myant Health's SKIIN chest band, mailed to the patient at home. The physician completes and signs it and faxes it to Myant Health.
- Completed by
- Ordering physician
- Issued by
- Dynacare, with Myant Health
- Format
- Fillable PDF
- Language
- English
-
LifeLabs' general Ontario requisition for tissue specimens that don't have their own pathology form, including breast specimens. The clinician who took the specimens completes and signs it.
- Completed by
- Requesting clinician or practitioner
- Issued by
- LifeLabs
- Format
- Fillable PDF
- Language
- English
-
Public Health Ontario's form for submitting a tick removed from a person for species identification. The clinician or health unit completes it with details from the patient.
- Completed by
- Health care provider or public health unit
- Issued by
- Public Health Ontario
- Format
- Fillable PDF
- Language
- English
Referrals
-
Dynacare's general referral for telegenetic counselling. The referring physician, midwife or nurse practitioner completes the patient details and reason for referral, signs, and faxes it.
- Completed by
- Referring physician, midwife or nurse practitioner
- Issued by
- Dynacare
- Format
- Fillable PDF
- Language
- English
-
Referral to the Child and Parent Resource Institute for a one-time developmental paediatrics or child and adolescent psychiatry consultation. A medical specialist completes the referral, and the child or substitute decision-maker signs the consent.
- Completed by
- Referring medical specialist; child or substitute decision-maker (consent)
- Issued by
- Child and Parent Resource Institute (CPRI), Ministry of Children, Community and Social Services
- Format
- Fillable PDF
- Language
- English (French version available)
Workers' compensation
- 1787A
ENT Consultation Report
Rapport de consultation ORL
WSIB's one-page report from an otolaryngologist on a worker's hearing loss, tinnitus, dizziness or balance complaint. The ENT specialist completes the whole form.
- Completed by
- Otolaryngologist (ENT specialist)
- Issued by
- Workplace Safety and Insurance Board (WSIB)
- Format
- Fillable PDF
- Language
- English and French
-
Détermination des capacités fonctionnelles pour la planification d'un retour au travail rapide et sécuritaire
WSIB form describing a worker's abilities and restrictions so the employer can plan modified work. The worker and employer complete Sections A and B, and the health professional completes Sections C to F.
- Completed by
- Worker and employer (Sections A and B); treating health professional (Sections C to F)
- Issued by
- Workplace Safety and Insurance Board (WSIB)
- Format
- Fillable PDF
- Language
- English and French
- Form REO8
Health Professional Continuity Report
Rapport du professionnel de la santé (continuation d'invalidité) (formulaire REO8)
WSIB's one-page report on a recurrence or re-injury of a previously accepted work-related condition. The treating health professional completes the whole form.
- Completed by
- Physician, nurse practitioner, chiropractor or physiotherapist
- Issued by
- Workplace Safety and Insurance Board (WSIB)
- Format
- Fillable PDF
- Language
- English and French
- Form 8
Health Professional's Report
WSIB's first report from a health professional after a patient's initial visit for a work-related injury or illness. The worker completes Section A and the health professional completes the rest.
- Completed by
- Worker (Section A); physician, nurse practitioner, chiropractor or physiotherapist (Sections B to F)
- Issued by
- Workplace Safety and Insurance Board (WSIB)
- Format
- Fillable PDF, or electronic submission
- Language
- English and French
-
WSIB's first report for a patient's work-related mental stress claim, used instead of Form 8. The patient completes Section A and a physician or nurse practitioner completes the rest.
- Completed by
- Patient (Sections A and G); physician or nurse practitioner (Sections B to F)
- Issued by
- Workplace Safety and Insurance Board (WSIB)
- Format
- Fillable PDF
- Language
- English and French
- 10880A
Medication Exception Form
Formulaire de demande d'exception pour un médicament
WSIB's request for coverage of a medication outside its drug formulary for a work-related injury or illness. Only the prescriber completes it, in Part A for non-opioids, Part B for opioids, or both.
- Completed by
- Prescriber (for example, physician or nurse practitioner)
- Issued by
- Workplace Safety and Insurance Board (WSIB)
- Format
- Fillable PDF
- Language
- English and French
-
Rapport d'évaluation initiale dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères
WSIB's initial assessment report when a worker with a concussion starts the mild traumatic brain injury program of care. The regulated health professional delivering the program completes it.
- Completed by
- Regulated health professional registered to deliver the mTBI program of care
- Issued by
- Workplace Safety and Insurance Board (WSIB)
- Format
- Fillable PDF
- Language
- English and French
- 0210A
Cannabis initial assessment form
Supports the decision about whether medical cannabis is covered for a condition related to work, when the board requests an initial assessment.
- Completed by
- Physician or NP
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 0148A
Chiropractor's treatment extension request
Demande de prolongation des traitements (chiropraticien)
Asks for more chiropractic treatment for a patient with a work injury who is not enrolled in a program of care.
- Completed by
- Chiropractor
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 0201A
Community Mental Health Program assessment form
Formulaire d'évaluation dans le cadre du Programme de santé mentale communautaire
Reports the first mental health assessment, including the diagnosis and functional impairment, of a patient who has been sent into the Community Mental Health Program.
- Completed by
- Community Mental Health Program provider (psychologist or other regulated mental health professional)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 0203A
Community Mental Health Program Progress Form
Formulaire d'évolution dans le cadre du Programme de santé mentale communautaire
Gives the board periodic updates on how a patient is responding to treatment through the Community Mental Health Program.
- Completed by
- Community Mental Health Program provider (psychologist or other regulated mental health professional)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 0204A
Community Mental Health Program Return to Work Recommendations
Recommandations concernant le retour au travail
Gives a mental health provider's advice about returning to work for a patient who is enrolled with the Community Mental Health Program.
- Completed by
- Community Mental Health Program provider (psychologist or other regulated mental health professional)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 0278A
Dental report
Rapport du dentiste
Reports a work-related dental injury, covering the patient's pre-accident dental history, findings, proposed treatment and fees.
- Completed by
- Dentist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 0211A
Follow-up cannabis assessment form
Supports a decision on whether coverage of medical cannabis for a work-related condition should continue, when the board asks for a follow-up.
- Completed by
- Physician or NP
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 2234A
Health professional continuity report (Form REO8)
Rapport du professionnel de la santé (continuation d'invalidité) (formulaire REO8)
Reports that a work condition already accepted by the board has recurred or the worker was injured again, including history, the earlier assessment and present status.
- Completed by
- Physician, NP, chiropractor or physiotherapist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 0896A
Health Professional's Progress Report (Form 26)
Rapport d'évolution (professionnel de la santé) (formulaire 26)
Follows a patient's recovery and how ready they are to go back to work, and is filled out when the patient brings in the form the board issued.
- Completed by
- Physician, NP, chiropractor, physiotherapist or RN (Extended Class)
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English and French
- 0008A
Health Professional's Report (Form 8)
Rapport du professionnel de la santé (formulaire 8)
Reports a patient's work-related injury or illness after the first visit, including cases where workplace factors may be involved; page 2 reaches the employer through the patient.
- Completed by
- Physician, NP, chiropractor or physiotherapist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 0010A
Health Professional's Report for Occupational Mental Stress (Form CMS8)
Rapport du professionnel de la santé pour stress professionnel (formulaire CMS8)
Opens a patient's claim for occupational mental stress with a first clinical report, and takes the place of Form 8 for these claims.
- Completed by
- Physician or NP only
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10585A
Hearing aid replacement and/or clinical exception request form
Formulaire de demande de remplacement de prothèse auditive et(ou) d'exception clinique
Requests approval for replacement hearing aids or clinical-exception-level devices, with a section for a physician's signature.
- Completed by
- Hearing instrument specialist or audiologist, with a physician signature section
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10688A
Hearing aid selection change form
Formulaire de modification du choix de prothèse auditive
Notes that a patient's hearing aids went back to the manufacturer and a different device was chosen instead.
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 3275A
Hearing assessment
Évaluation audiologique
Reports audiometry results and a recommendation about hearing aids, either for a claim of hearing loss caused by noise or for hearing services.
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10584A
Hearing assistive technologies (HAT) request form
Formulaire de demande de technologies d'aide auditive
Asks the board for approval ahead of time before a patient first buys any hearing assistive technology.
- Completed by
- Audiologist or hearing instrument specialist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10702A
Hearing services initial bundle outcome report
Forfait de services auditifs initiaux – Rapport des résultats
Reports the outcome after the first bundle of hearing services has been provided, covering fitting of the hearing aid and the follow-up visits.
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10692A
Hearing services mini bundle outcome report
Miniforfait de services auditifs – Rapport des résultats
Reports the result of the mini bundle of hearing services, for instance when a new prescription leads to approved replacement hearing aids.
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10708A-10715A
Interdisciplinary team program of care reports (8 forms)
Groups the initial, mid-point, outcomes and supplementary reports for the interdisciplinary team program of care, and each one has a version for work hardening.
- Completed by
- Contracted interdisciplinary team (at minimum a physiotherapist or chiropractor plus an occupational therapist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10708A
Interdisciplinary team program of care: Initial assessment report
Opens an interdisciplinary team program of care with a joint first assessment that includes work and job-demand factors.
- Completed by
- Contracted interdisciplinary team (physiotherapist or chiropractor plus occupational therapist, at minimum)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 0298A
Medical clearance for functional abilities evaluation (FAE)
Confirms a patient is medically fit to go through a functional abilities evaluation arranged for their work injury claim.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 10393A
Mild traumatic brain injury program of care: Care and outcomes summary
Sommaire des soins et des résultats dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères
Closes out the mild traumatic brain injury program of care at discharge, summarizing care, outcomes and the patient's employment status.
- Completed by
- Regulated health professional delivering the WSIB mTBI program of care
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10392A
Mild traumatic brain injury program of care: Mid-point report
Rapport de mi-parcours dans le cadre du Programme de soins pour les lésions cérébrales traumatiques légères
Marks the end of block one in the mild traumatic brain injury program of care with a mid-point progress report.
- Completed by
- Regulated health professional delivering the WSIB mTBI program of care
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10394A
Mild traumatic brain injury program of care: Supplementary report
Reports on the extra block of mild traumatic brain injury treatment once the board has approved it.
- Completed by
- Regulated health professional delivering the WSIB mTBI program of care
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English
- 10637A
Musculoskeletal (MSK) program of care: Care and outcomes summary
Sommaire des soins et des résultats dans le cadre du Programme de soins musculo-squelettiques
Closes the musculoskeletal program of care with a summary of the care given and the outcomes, written at the end of the second block or on early discharge.
- Completed by
- Regulated health professional delivering the WSIB MSK program of care (e.g., physiotherapist, chiropractor)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10635A
Musculoskeletal (MSK) program of care: Initial assessment report
Rapport d'évaluation initiale dans le cadre du Programme de soins musculo-squelettiques
Starts a musculoskeletal program of care with the first assessment of a work-related injury, including the patient's functional abilities.
- Completed by
- Regulated health professional delivering the WSIB MSK program of care (e.g., physiotherapist, chiropractor)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10636A
Musculoskeletal (MSK) program of care: Mid-point report
Rapport de mi-parcours dans le cadre du Programme de soins musculo-squelettiques
Reviews how the patient has progressed after the first block of the musculoskeletal program of care, and may be skipped when the patient is discharged early.
- Completed by
- Regulated health professional delivering the WSIB MSK program of care (e.g., physiotherapist, chiropractor)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10638A
Musculoskeletal (MSK) program of care: Supplementary report
Rapport complémentaire dans le cadre du Programme de soins musculo-squelettiques
Reports on an approved extra treatment block within the musculoskeletal program of care.
- Completed by
- Regulated health professional delivering the WSIB MSK program of care (e.g., physiotherapist, chiropractor)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 10687A
Ongoing hearing services report
Rapport sur les services auditifs continus
Records the routine hearing aid upkeep, such as cleaning and maintenance, done at each visit in the ongoing services bundle.
- Completed by
- Hearing health care provider (audiologist or hearing instrument specialist)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
-
Opioid assessment form
Answers the board's questions about the medical reasons for a patient's opioid medication and how much it helps.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 0389A
Physician's report - home oxygen therapy
Documents home oxygen that was prescribed for a condition related to work, and it is required for initial entitlement as well as continuing entitlement.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 0425A
Physician's report - vibration induced white finger disease (Form 8W)
Comes in when a patient reports vibration-induced white finger related to work, and the physician fills it out and sends it back.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 0407A
Physician's report on occupational chest disease (Form 8S)
Comes in when a patient reports a chest or respiratory illness related to work, and the physician fills it out and sends it back.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 0307A
Physician's report on occupational disease (Form 8D)
Arrives when a patient reports an occupational illness, and the treating physician or NP completes and returns it to document the condition.
- Completed by
- Physician or NP
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 0353A
Physician's report on skin disease (Form 8D2)
Comes in when a patient reports a skin condition related to work, and the physician fills it out and sends it back to support the claim.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 0043A
Physician's special report
Provides the clinical basis for rating a permanent disability when the workplace accident took place prior to January 1, 1990.
- Completed by
- Physician
- Issued by
- WSIB
- Format
- Sent for each case
- Language
- English
- 0153A
Physiotherapist's treatment extension request
Demande de prolongation des traitements de physiothérapie
Asks for more physiotherapy for a patient with a work injury who is not enrolled in a program of care.
- Completed by
- Physiotherapist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
- 0856A
Physiotherapy assessment report
Rapport d'évaluation de physiothérapie
Provides the physiotherapist's findings and treatment plan for an injury related to work, along with details about the patient and the employer.
- Completed by
- Physiotherapist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Insurance claims
- OCF-3
Disability Certificate
The Ontario auto insurance form that certifies an accident victim's injuries and disability for accident benefits. The applicant completes Parts 1 to 4 and a health practitioner completes Parts 5 to 10.
- Completed by
- Applicant (Parts 1 to 4); health practitioner (Parts 5 to 10)
- Issued by
- Financial Services Regulatory Authority of Ontario (Statutory Accident Benefits Schedule)
- Format
- Fillable PDF
- Language
- English and French
-
The Ontario auto insurance form that asks the insurer to approve treatment, assessments or goods for an accident victim. The applicant provides Parts 1 and 2 and signs, a health practitioner signs Part 4, and a regulated health professional prepares the rest.
- Completed by
- Applicant (Parts 1 and 2, signature in Part 10, initials in Part 12); health practitioner (Part 4); regulated health professional (Part 3, Parts 5 to 9, 11 and 12)
- Issued by
- Financial Services Regulatory Authority of Ontario (Statutory Accident Benefits Schedule)
- Format
- Fillable PDF
- Language
- English and French
- OCF-19
Application for Determination of Catastrophic Impairment
Demande de détermination pour une déficience invalidante
Certifies that a person meets the catastrophic impairment criteria after an auto accident, which raises their benefit limits.
- Completed by
- Physician; a neuropsychologist may complete it if the impairment is a brain impairment only
- Issued by
- FSRA (Ontario SABS)
- Format
- Fillable PDF
- Language
- English and French
- Form 1
Assessment of Attendant Care Needs
Évaluation des besoins des personnes soignantes modifiée
Calculates a monthly attendant care benefit after documenting a patient's needs at care levels 1 to 3.
- Completed by
- Assessor (typically an occupational therapist or registered nurse)
- Issued by
- FSRA (Ontario SABS)
- Format
- Fillable PDF
- Language
- English and French
- OCF-24
Minor Injury Treatment Discharge Report
Rapport de congé de traitement aux fins de la Ligne directrice sur les blessures légères
Closes out minor injury treatment by recording the insured person's discharge and functional status.
- Completed by
- Health practitioner who provided MIG treatment
- Issued by
- FSRA (Ontario SABS)
- Format
- Fillable PDF
- Language
- English and French
- OCF-23
Treatment Confirmation Form
Formulaire de confirmation pré-approuvé du traitement de la structure
Confirms that an auto accident injury fits the Minor Injury Guideline, which starts pre-approved treatment under that guideline.
- Completed by
- Initiating health practitioner authorized by law to treat the impairment
- Issued by
- FSRA (Ontario SABS)
- Format
- Fillable PDF
- Language
- English and French
Government benefits and tax credits
-
The Ontario Disability Support Program application for medical transportation and medical supplies, items and devices. The applicant completes their information and signs the declaration, and a health care professional completes the rest.
- Completed by
- Applicant (applicant information and declaration); physician, nurse practitioner, registered nurse, physician assistant, occupational therapist, physiotherapist or psychologist (health care professional sections)
- Issued by
- Ontario Ministry of Children, Community and Social Services (ODSP)
- Format
- Fillable PDF, or online through MyBenefits
- Language
- English and French
-
The Ontario Disability Support Program request for hearing aid items or services beyond the standard benefit. A registered ADP hearing aid authorizer completes it, and the applicant signs the declaration in Section D.
- Completed by
- Registered Assistive Devices Program (ADP) hearing aid authorizer; applicant signs Section D
- Issued by
- Ontario Ministry of Children, Community and Social Services (ODSP)
- Format
- Fillable PDF
- Language
- English and French
-
2026-27 OSAP Disability Verification Form: Students Attending Ontario Public Postsecondary Institutions
RAFEO 2026-2027 - Formulaire de vérification de l'invalidité : Étudiants qui fréquentent des établissements d'études postsecondaires publics de l'Ontario
Verifies a permanent or persistent or prolonged disability so a student at an Ontario public institution can qualify for OSAP disability funding and a reduced course load.
- Completed by
- Physician, NP or other regulated health care professional whose scope includes diagnosing (checkboxes: audiologist/SLP, chiropractor, neurologist, OT, optometrist, ophthalmologist, family physician, psychiatrist, other physician, physiotherapist, psychologist/psychological associate/neuropsychologist, rheumatologist)
- Issued by
- OSAP (Ministry of Colleges, Universities, Research Excellence and Security)
- Format
- Fillable PDF
- Language
- English and French
-
2026-27 OSAP Disability Verification Form: Students Attending Private Institutions or OSAP-approved Institutions outside of Ontario
RAFEO 2026-2027 - Formulaire de vérification de l'invalidité : Étudiants qui fréquentent des établissements privés ou des établissements approuvés par le RAFEO à l'extérieur de l'Ontario
Verifies a student's disability for OSAP when they go to a private school or an approved school outside Ontario, with a further section for recommended accommodations and supports.
- Completed by
- Physician, NP or other regulated health care professional whose scope includes diagnosing (same checklist as the PUB version)
- Issued by
- OSAP (Ministry of Colleges, Universities, Research Excellence and Security)
- Format
- Fillable PDF
- Language
- English and French
-
Activities of Daily Living Index (ADLI) - ODSP Disability Determination Package
Describes how an applicant's impairment restricts their activities of daily living, and is required for the disability determination decision.
- Completed by
- Physician, NP, RN, psychologist or psychological associate, optometrist, OT, physiotherapist, chiropractor, audiologist, speech-language pathologist, or social worker
- Issued by
- ODSP (MCCSS) - Disability Adjudication Unit
- Format
- Online portal or EMR
- Language
- English and French
- 3090E
Adopted Person's and Descendant of Adopted Person's Application to Request a Severe Medical Search
Demande de recherche présentée par une personne adoptée ou l'un de ses descendants en raison de graves problèmes de santé
Allows an adopted person or their descendant to ask the ministry to locate birth relatives when a severe illness makes finding them a medical need.
- Completed by
- Physician or other regulated health care professional
- Issued by
- MCCSS (adoption information disclosure)
- Format
- Language
- English and French
- 3111 / 3112
Application for Special Diet Allowance
Confirms which medical conditions entitle an Ontario Works or ODSP recipient to a monthly diet allowance.
- Completed by
- Physician (CPSO), RN(EC)/nurse practitioner, registered dietitian, registered midwife (only for inadequate lactation or when breast-feeding is contraindicated), or traditional Aboriginal midwife
- Issued by
- Ontario Works / ODSP (MCCSS)
- Format
- Sent for each case
- Language
- English and French
- 3089E
Birth Family Member's Application to Request a Severe Medical Search
Demande de recherche présentée par un membre de la famille généalogique en raison de graves problèmes de santé
Allows a member of a birth family to ask the ministry to look for an adopted person or that person's relatives because of a serious physical or mental illness.
- Completed by
- Physician or other regulated health care professional (CPSO member, FRCP/FRCS, registered psychologist, nurse in the extended class, other)
- Issued by
- MCCSS (adoption information disclosure)
- Format
- Language
- English and French
-
Health Status Report (HSR) - ODSP Disability Determination Package
Forms the core medical evidence adjudicators use to decide whether an applicant counts as a person with a disability under the program.
- Completed by
- Physician, NP, registered nurse, psychologist or psychological associate, or optometrist
- Issued by
- ODSP (MCCSS) - Disability Adjudication Unit
- Format
- Online portal or EMR
- Language
- English and French
- OPB 3003
Medical Examination Report – Public Service Pension Plan (PSPP)
Supports a member's first or reassessed disability benefit application under the public service pension plan.
- Completed by
- Physician or medical professional recognized by a Canadian or US medical association
- Issued by
- Ontario Pension Board
- Format
- Fillable PDF
- Language
- English
- OPB 3013
Medical Examination Report for a Disabled Dependant – Public Service Pension Plan (PSPP)
Establishes that a deceased member's dependant has a continuing disability, so a survivor pension can be paid.
- Completed by
- Dependant's physician (recognized by a Canadian or US medical association)
- Issued by
- Ontario Pension Board
- Format
- Fillable PDF
- Language
- English
- 147
Medical Report - OMERS Total Disability Benefits
Gives the doctor's medical report behind a request to waive pension contributions or grant a disability pension.
- Completed by
- Member's doctor
- Issued by
- OMERS
- Format
- Language
- English
- 0202
Medical Report – Disability Pension
Documents a teacher's medical condition when seeking pre-approval of a full or partial disability pension or applying for one, and an independent referee reviews the report.
- Completed by
- Medical examiner (treating physician)
- Issued by
- Ontario Teachers' Pension Plan
- Format
- Language
- English
- 3203E
ODSP Hearing Aid Benefit (Exceptional Circumstances)
Prestation pour prothèses auditives du POSPH (cas exceptionnels)
Asks for pre-authorization of hearing aid items or services that go past the usual benefit in exceptional circumstances, and only a registered ADP authorizer may submit it.
- Completed by
- Registered Assistive Devices Program (ADP) hearing aid authorizer only (e.g., audiologist)
- Issued by
- ODSP (MCCSS)
- Format
- Fillable PDF
- Language
- English and French
-
ODSP Medical Review Package - Part A
Brings an existing recipient's conditions up to date compared with those recorded at their first disability determination.
- Completed by
- Physician, NP, RN, psychologist or psychological associate, or optometrist
- Issued by
- ODSP (MCCSS) - Disability Adjudication Unit
- Format
- Sent for each case
- Language
- English and French
-
ODSP Medical Review Package - Part B (Health Status Report and Activities of Daily Living)
Adds conditions Part A does not list during a recipient's medical review, using a health status report plus an activities of daily living section.
- Completed by
- HSR: physician, NP, RN, psychologist or psychological associate, or optometrist. ADL: also chiropractor, physiotherapist, OT, social worker, audiologist, or SLP.
- Issued by
- ODSP (MCCSS) - Disability Adjudication Unit
- Format
- Sent for each case
- Language
- English and French
- ON00646E
Ontario Disability Support Program (ODSP) - Mandatory Special Necessities (MSN) Benefit Application
Programme ontarien de soutien aux personnes handicapées (POSPH) Demande de Prestations obligatoires pour les nécessités spéciales
Confirms a recipient's medical need for transportation to appointments and therapy, plus diabetic or surgical supplies, dressings and devices.
- Completed by
- Physician, NP, RN, OT, physiotherapist or physician assistant licensed in Ontario; psychologists may complete only the Medical Transportation section
- Issued by
- ODSP (MCCSS)
- Format
- Fillable PDF
- Language
- English and French
- 23-0217
Request for Priority: Terminally Ill
Requests priority placement on Toronto's waiting list for rent-geared-to-income housing, supported by a physician's confirmation of a terminal illness with under two years expected.
- Completed by
- Physician
- Issued by
- City of Toronto (Access to Housing)
- Format
- Fillable PDF
- Language
- English
- 30-0001
Special Priority Program (SPP) Application
Confirms the applicant has survived domestic or family abuse or human trafficking, so they can receive special priority on the social housing waiting list in Toronto.
- Completed by
- Qualified professional, e.g., doctor, RN or RPN, registered mental health therapist or psychotherapist, midwife, among others listed
- Issued by
- City of Toronto (Access to Housing)
- Format
- Fillable PDF
- Language
- English
- 3183E
Vision Care Benefit (Exceptional Circumstances)
Demande de prestations pour soins de la vue (circonstances exceptionnelles)
Asks for pre-authorization of medically necessary vision items missing from the social assistance fee schedule, such as medically necessary contact lenses.
- Completed by
- Vision care service provider (e.g., optometrist or optician) registered as a supplier
- Issued by
- ODSP / Ontario Works (MCCSS)
- Format
- Fillable PDF
- Language
- English and French
Drug coverage
-
Demande de produit médicamenteux ne figurant pas dans la liste, Programme d'accès exceptionnel (PAE)
Ontario's general request for Ontario Drug Benefit coverage of a drug not on the formulary, or not listed for the patient's use. An authorized prescriber completes all six sections and signs.
- Completed by
- Authorized prescriber (physician or nurse practitioner)
- Issued by
- Ontario Ministry of Health, Drug Programs Delivery Branch
- Format
- Fillable PDF
- Language
- English and French
- 4551-87E
Application and Consent for the Inherited Metabolic Diseases (IMD) Program
Formulaire de demande et de consentement Programme de dépistage de maladies métaboliques héréditaires
Enrols a patient in Ontario's program for inherited metabolic diseases and records the patient's or substitute decision-maker's consent.
- Completed by
- Treating physician (or another physician completing the application) plus patient/SDM consent
- Issued by
- Ministry of Health - Inherited Metabolic Diseases Program
- Format
- Fillable PDF
- Language
- English and French
- ON00521E
Exceptional Access Program (EAP) - Biosimilar Exemption Request
Programme d’Accès Exceptionnel – Formulaire de demande d’exemption pour les produits biosimilaires
Exempts a patient from Ontario's policy of switching to biosimilars so they can stay on, or return to, an originator biologic funded through the program.
- Completed by
- Prescriber
- Issued by
- Ministry of Health - Ontario Drug Benefit (EAP)
- Format
- Fillable PDF
- Language
- English and French
-
Exceptional Access Program (EAP) drug-specific request forms
Captures the funding criteria that apply to particular drugs through electronic request forms, used when a patient needs a drug outside the regular Ontario benefit list.
- Completed by
- Authorized prescriber (physician or NP)
- Issued by
- Ministry of Health - Ontario Drug Benefit (EAP)
- Format
- Fillable PDF
- Language
- English and French
- 4940-87E
Exceptional Access Program (EAP) Request OxyNEO (Oxycodone Hydrochloride Controlled Release) Tablets
Requests coverage of OxyNEO tablets as a new request, renewal or appeal, and includes prescriber statements on the risk of misuse and opioid stewardship.
- Completed by
- Authorized prescriber (physician or NP)
- Issued by
- Ministry of Health - Ontario Drug Benefit (EAP)
- Format
- Fillable PDF
- Language
- English
- 4908-87E
Initial Request for Compassionate Review Policy
Demande initiale – Politique d'examen pour l'accès compassionnel aux médicaments
Asks the Ontario program to fund a drug for an eligible patient whose circumstances fall under the compassionate review policy.
- Completed by
- Physician (prescriber)
- Issued by
- Ministry of Health - Ontario Drug Benefit (EAP)
- Format
- Fillable PDF
- Language
- English and French
- 3057-87
Nutrition Products
Produits nutritionnels
Makes a nutrition product reimbursable when the patient depends on it as their only nourishment and the criteria are met; the pharmacist completes the dispensing portion.
- Completed by
- Prescriber (physician/NP) - Section 1; pharmacist completes the dispensing part
- Issued by
- Ministry of Health - Ontario Drug Benefit
- Format
- Fillable PDF
- Language
- Bilingual
- 0225-47
Recombinant Human Erythropoietin Funding Enrollment for E.S.R.D. Patients
Inscription à l'aide financière pour malades souffrant d'insuffisance rénale terminale
Enrols a patient with end-stage renal disease in publicly funded erythropoietin treatment, usually through the hospital renal program.
- Completed by
- Treating physician / hospital renal program
- Issued by
- Ministry of Health - Special Drugs Program
- Format
- Language
- Bilingual
- 2772-87E
Special Authorization (Allergen)
Autorisation spéciale (allergène)
Authorizes coverage of allergen extracts for immunotherapy as an Ontario Drug Benefit, which a physician or nurse practitioner prescriber must sign.
- Completed by
- Prescriber (physician - CPSO, or NP - CNO)
- Issued by
- Ministry of Health - Ontario Drug Benefit
- Format
- Fillable PDF
- Language
- English and French
Driving and licensing
- 5108E
Medical Condition Report
The Ministry of Transportation form for reporting a patient with a medical condition that may make driving dangerous. A physician, nurse practitioner or occupational therapist completes all of it.
- Completed by
- Physician, nurse practitioner or occupational therapist (occupational therapists for discretionary reports only)
- Issued by
- Ontario Ministry of Transportation
- Format
- Fillable PDF
- Language
- English and French
-
The Ministry of Transportation form optometrists use to report a patient's visual impairment that may make driving dangerous. The optometrist completes all of it.
- Completed by
- Optometrist
- Issued by
- Ontario Ministry of Transportation
- Format
- Fillable PDF
- Language
- English and French
- SR-LC-080E
Commercial Driver Medical Report
Documents the periodic medical for class A to F applicants and holders: every five years under 46, every three from 46 to 64, then yearly.
- Completed by
- Physician or NP
- Issued by
- MTO
- Format
- Fillable PDF
- Language
- English and French
- 5080E
FMCSA Driver Medical Report
Confirms medical fitness for class G licence holders who drive commercial vehicles in the United States under FMCSA rules.
- Completed by
- Physician or NP
- Issued by
- MTO
- Format
- Fillable PDF
- Language
- English and French
- 5108E
Medical Condition Report
Notifies the Registrar of a patient with a high-risk condition on the prescribed list, or another condition that could make driving unsafe, in a mandatory or optional report.
- Completed by
- Physician, NP or occupational therapist (OTs discretionary only)
- Issued by
- MTO
- Format
- Fillable PDF
- Language
- English and French
- 5109E
Vision Report to the Registrar of Motor Vehicles
Flags a visual impairment that could make driving dangerous, as a required report (Section A) or at the optometrist's own discretion (Section B).
- Completed by
- Optometrist
- Issued by
- MTO
- Format
- Fillable PDF
- Language
- English and French
Mental health and medico-legal
- Form 1 (6427-41)
Application by Physician for Psychiatric Assessment
Demande d'évaluation psychiatrique faite par un médecin
The Mental Health Act form a physician signs to have a person taken to a psychiatric facility and held for assessment. Only the examining physician completes it.
- Completed by
- The physician who personally examined the person
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- Form 3 (6429-41)
Certificate of Involuntary Admission
Certificat d'admission en cure obligatoire
The Mental Health Act certificate that admits a person to a psychiatric facility as an involuntary patient. The attending physician at the facility completes it.
- Completed by
- Attending physician at the psychiatric facility
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- Form 4 (6430-41)
Certificate of Renewal
Certificat de renouvellement
The Mental Health Act certificate that extends an involuntary patient's detention when a Form 3 or an earlier renewal is about to expire. The attending physician completes it.
- Completed by
- Attending physician at the psychiatric facility
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- Form 5 (1972-41)
Change to Informal or Voluntary Status
The Mental Health Act form the attending physician signs to end a patient's involuntary status and continue them as an informal or voluntary patient. The attending physician completes all of it.
- Completed by
- Attending physician
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- Form 45 (3760-41)
Community Treatment Order
The Mental Health Act form a physician uses to issue or renew a community treatment order. The physician completes Parts 1 and 3, and the person or their substitute decision-maker signs the undertaking in Part 2.
- Completed by
- Issuing or renewing physician (Parts 1 and 3); the person or their substitute decision-maker (Part 2 undertaking)
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- Form 49 (3764-41)
Notice of Intention to Issue or Renew Community Treatment Order
The Mental Health Act notice a physician gives a person, and their substitute decision-maker, before issuing or renewing a community treatment order. The physician completes and signs all four parts.
- Completed by
- Physician considering issuing or renewing the community treatment order
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- Form 46 (3762-41)
Notice to Person of Issuance or Renewal of Community Treatment Order
Avis de prise ou de renouvellement d'une ordonnance de traitement en milieu communautaire
The Mental Health Act notice a physician gives a person when a community treatment order is issued or renewed. The physician completes and signs it, and it tells the person about their right to a Consent and Capacity Board hearing.
- Completed by
- Physician who issued or renewed the community treatment order
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French (bilingual form)
- Form 42 (1787-41)
Notice to Person under Subsection 38.1 of the Act of Application for Psychiatric Assessment under Section 15 or an Order under Section 32 of the Act
The written notice a person held for psychiatric assessment must receive, telling them why they're detained and that they can retain a lawyer. The attending physician completes and delivers it.
- Completed by
- Attending physician at the psychiatric facility
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- Form 47 (3761-41)
Order for Examination
The Mental Health Act order a physician issues when a person on a community treatment order stops complying. The physician completes and signs it, and it directs police to bring the person for examination.
- Completed by
- Physician who issued or renewed the community treatment order
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- ON00325E
Application for Emergency Admission to Secure Treatment Program
Demande de placement d'urgence dans un programme de traitement en milieu fermé
Requests emergency admission of a child into a secure treatment program, and a physician is among those who may file it.
- Completed by
- Applicant, who may be a physician (or a parent, child protection worker, or CAS officer)
- Issued by
- Ministry of Health (Child, Youth and Family Services Act secure treatment)
- Format
- Fillable PDF
- Language
- English and French
- 0005-54E
Certificate of Death - Form 1 (Public Hospitals Act)
Certificat de décès
Certifies a patient's death in hospital, completed before the body is released under the Public Hospitals Act regulation.
- Completed by
- Attending physician or RN in the extended class
- Issued by
- Ministry of Health (Public Hospitals Act, R.R.O. 1990, Reg. 965)
- Format
- Fillable PDF
- Language
- English and French
-
Do Not Resuscitate Confirmation Form
Formulaire de confirmation d'ordonnance de ne pas réanimer
Confirms that an order not to resuscitate is in place, and is meant for regulated health care providers and staff of health care facilities.
- Completed by
- Regulated health care provider (CFR: health care facility staff and regulated health care providers)
- Issued by
- Ministry of Health
- Format
- Sent for each case
- Language
- English and French
- ON00460E
Form 1 - Physician/Nurse Practitioner Report (Mandatory Blood Testing Act, 2006)
Rapport du médecin/de l’infirmière ou l’infirmier praticien
Supports an application, for example by a first responder or a victim, to have someone else's blood tested following exposure to their bodily fluids.
- Completed by
- Reporting physician or NP
- Issued by
- Ministry of Health (Mandatory Blood Testing Act)
- Format
- Fillable PDF
- Language
- English and French
- 6440-41
Form 21 - Certificate of Incapacity to Manage One's Property under Subsection 54(4) of the Act
Formule 21 - Cetificat d'incapacité de gestion des biens en vertu du paragraphe 54(4) de la Loi
Certifies that a patient in a psychiatric facility cannot manage their own property, so someone else can take over their financial affairs.
- Completed by
- Attending physician
- Issued by
- Ministry of Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- ON00502E
Laboratory Requisition (Mandatory Blood Testing Act)
Demande d’analyse en laboratoire
Orders the blood tests on the respondent once a mandatory blood testing application has gone forward.
- Completed by
- Physician or NP ordering the tests (or tests ordered on the authority of the Consent and Capacity Board)
- Issued by
- Ministry of Health (Mandatory Blood Testing Act)
- Format
- Fillable PDF
- Language
- English and French
- 11291E
Medical Certificate of Death - Form 16
Certificat médical de décès – Formulaire 16
States the medical cause of a death so that it can be registered according to the Vital Statistics Act.
- Completed by
- Physician, coroner, coroner investigator, RN(EC)/NP or RN (as listed on the signature line)
- Issued by
- Office of the Registrar General (ServiceOntario)
- Format
- Fillable PDF
- Language
- English and French
-
Mental Health Act forms completed by physicians
Gathers the Ontario statutory forms physicians sign for involuntary assessment, admission, renewal, a change of status, capacity certificates and orders for community treatment.
- Completed by
- Physician (attending physician or physician issuing the CTO)
- Issued by
- Ministry of Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- 4895-64E
Statement of Medical Exemption - Immunization of School Pupils Act
Déclaration d'exemption médicale – Loi sur l'immunisation des élèves
Exempts a student from one or more vaccines that school attendance would otherwise require, according to Ontario's school pupils immunization legislation.
- Completed by
- Physician or NP (RN in the extended class)
- Issued by
- Ministry of Health (public health)
- Format
- Fillable PDF
- Language
- English and French
- 3041E
Statement of Medical Exemption (Child Care and Early Years Act)
Déclaration d'exemption médicale
Exempts a child from the vaccines normally required by a child care centre with a licence or by a home child care agency.
- Completed by
- Regulated health professional (as named on the form)
- Issued by
- Ministry of Education (child care licensing)
- Format
- Fillable PDF
- Language
- English and French
Parking, transit and travel
-
Demande de permis de stationnement accessible (PSA)
ServiceOntario's application for an accessible parking permit. The applicant completes Part A and a regulated healthcare practitioner certifies the qualifying condition in Part B.
- Completed by
- Applicant or representative (Part A); regulated healthcare practitioner (Part B)
- Issued by
- ServiceOntario
- Format
- Fillable PDF, or online application with a photo of the signed form
- Language
- English and French
-
Ontario's application for help with travel and lodging costs when a Northern Ontario resident travels to a specialist or ministry-funded facility. The patient completes Sections 1 to 5 and the specialist completes Section 6.
- Completed by
- Patient, guardian or substitute decision-maker (Sections 1 to 5); specialist or ministry-funded facility (Section 6)
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF, or online application
- Language
- English and French
- SR-LV-129E
Application for an Accessible Parking Permit (APP)
A clinician certifies the condition that qualifies a patient for an Ontario accessible parking permit, whether it is a first permit, a renewal or a replacement.
- Completed by
- Physician, NP (Extended Class), occupational therapist, physiotherapist, chiropractor or chiropodist/podiatrist
- Issued by
- ServiceOntario
- Format
- Fillable PDF
- Language
- English and French
- 0327-88E
Application for Northern Health Travel Grant
Demande de subvention accordée aux résidents du Nord de l'Ontario pour frais de transport à des fins médicales
Used by Northern Ontario residents to claim reimbursement for travel and lodging when they go a long way to see an OHIP-insured specialist or a ministry-funded facility.
- Completed by
- Specialty-service provider (specialist physician or approved facility)
- Issued by
- Ministry of Health - Northern Health Travel Grant (NHTG)
- Format
- Fillable PDF
- Language
- English and French
-
ATS Application Form - General
Confirms a patient's disability and its functional impact to establish eligibility for Hamilton's specialized transit service.
- Completed by
- Physician, NP, RN, chiropractor, physiotherapist, OT or regulated/licensed MSW
- Issued by
- City of Hamilton (Accessible Transportation Services / DARTS)
- Format
- Fillable PDF
- Language
- English
-
ATS Application Form - Residents of Long-Term Care
Confirms eligibility for Hamilton's specialized transit service for patients who live in a long-term care home.
- Completed by
- Physician, NP, RN, chiropractor, physiotherapist, OT or regulated/licensed MSW
- Issued by
- City of Hamilton (Accessible Transportation Services / DARTS)
- Language
- English
-
Mobility On-Request Paratransit Application Package
Confirms the patient's medical condition and what they can and cannot do, so York Region can decide whether they qualify for paratransit.
- Completed by
- Licensed physician, NP, RN, RPN, registered OT, physiotherapist, psychologist, licensed optometrist/ophthalmologist or social worker (MSW, RSW)
- Issued by
- York Region Transit (YRT)
- Format
- Fillable PDF
- Language
- English
-
MobilityPLUS Application - Health/Disability Professional form
The health professional completes this section of the Waterloo Region MobilityPLUS application, describing the patient's disabilities and how well they can ride regular buses.
- Completed by
- Health/disability professional who can speak to the applicant's disabilities, e.g., physician, NP, psychologist, physiotherapist, OT, social worker or kinesiologist; managers of pre-approved adult day programs or LTC centres; other Region-approved professionals
- Issued by
- Grand River Transit (Region of Waterloo)
- Format
- Fillable PDF
- Language
- English
-
Specialized Services Application and Information Package
Assesses which tasks the patient can do when riding conventional buses, so Durham Region can decide if they qualify for its paratransit service.
- Completed by
- Physician, NP, RN/RPN, physiotherapist, OT or kinesiologist
- Issued by
- Durham Region Transit
- Format
- Language
- English
-
Specialized Transit Services Application
After going over the applicant's own answers, the clinician certifies the disability and how it affects riding fixed-route buses, for London's paratransit service.
- Completed by
- Licensed physician, physiotherapist, optometrist/ophthalmologist, registered OT, psychologist/psychiatrist, NP or RN
- Issued by
- London Transit Commission
- Format
- Fillable PDF
- Language
- English
- ON00857E
Specialty-Service Provider Form for Northern Health Travel Grant
Formulaire du fournisseur de services spécialisés pour la subvention aux résidents du Nord pour frais de transport à des fins médicales
Confirms an OHIP-insured specialist service and the nights of lodging needed, and is attached to a patient's online Northern Health Travel Grant application.
- Completed by
- Specialty-service provider (specialist physician or approved facility)
- Issued by
- Ministry of Health - Northern Health Travel Grant (NHTG)
- Format
- Fillable PDF
- Language
- English and French
- V-10-048
TransHelp service eligibility application form
Describes a patient's disabilities, how long they last and how they limit conventional transit, to qualify for TransHelp in Brampton, Mississauga and Caledon.
- Completed by
- Physician, NP, psychiatrist, psychologist, physiotherapist, OT, optometrist, audiologist, chiropractor, speech-language pathologist or regulated social worker; RN for long-term care residents
- Issued by
- Peel Region (TransHelp)
- Format
- Fillable PDF
- Language
- English
-
Wheel-Trans eligibility application
Describes the patient's disabilities and the ways they restrict riding regular buses and subways, so the patient can qualify for Toronto's door-to-door Wheel-Trans service.
- Completed by
- Physician, psychiatrist, physiotherapist, optometrist, audiologist, psychologist, chiropractor, OT, speech-language pathologist, RN or regulated/licensed MSW (as appropriate to the disability)
- Issued by
- TTC
- Format
- Fillable PDF
- Language
- English
Health programs
-
The Assistive Devices Program application for a grant toward external silicone breast prostheses. The applicant, or their agent, completes and signs it after buying the prosthesis.
- Completed by
- Applicant or their agent
- Issued by
- Ontario Ministry of Health, Assistive Devices Program
- Format
- Fillable PDF
- Language
- English and French
-
The health assessment Ontario requires when a person applies for long-term care. A physician, nurse practitioner or registered nurse completes it and sends it to Ontario Health atHome.
- Completed by
- Physician, nurse practitioner (RN extended class) or registered nurse
- Issued by
- Ontario Ministry of Long-Term Care
- Format
- Fillable PDF
- Language
- English and French
-
Demande d'exemption médicale, Carte Santé
Ontario's request to renew or register a health card without a photo or signature, or without attending ServiceOntario, for medical reasons. The cardholder or legal representative completes Part A and a physician or nurse practitioner completes Part B.
- Completed by
- Health card holder or legal representative (Part A); physician or nurse practitioner (Part B)
- Issued by
- Ontario Ministry of Health and ServiceOntario
- Format
- Fillable PDF
- Language
- English and French (bilingual form)
-
Certificat médical, Loi sur les services d'aides familiales et d'infirmières visiteuses
The attending physician's certificate that supports an application for a visiting registered nurse under Ontario's Homemakers and Nurses Services Act. The physician completes the whole form.
- Completed by
- Attending physician
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French (bilingual form)
-
Déclaration d'exemption médicale, Loi sur l'immunisation des élèves
Ontario's medical exemption from one or more vaccines required for school attendance. A physician or nurse practitioner completes and signs it, and the parent submits it to the local public health unit.
- Completed by
- Physician or nurse practitioner (registered nurse in the extended class)
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- 5063-67E
Addendum for Ventilator Equipment and Supplies Application Form
Adds the patient's primary and secondary diagnoses to a ventilator equipment and supplies application.
- Completed by
- Physician
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English
- 4793-67E
Application for Funding - Respiratory Equipment & Supplies
Demande de financement Équipement et fournitures respiratoires
Requests funding for respiratory equipment such as CPAP machines for sleep apnea, backed by a sleep-lab diagnosis from the prescriber.
- Completed by
- Physician or NP (prescriber; sleep-lab diagnosis); vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4825-67E
Application for Funding Communication Aids
Demande de financement Aides à la communication
Requests funding for devices that help a patient communicate, usually assessed at an ADP communication aids clinic after a physician or NP diagnoses the need.
- Completed by
- Physician or NP (diagnosis) and ADP-registered authorizer (e.g., at an ADP communication aids clinic); vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4791-67E
Application for Funding Enteral Feeding Pump and Supplies
Demande de financement Pompe et matériel d'alimentation entérale
Asks for funding of an enteral feeding pump and its supplies once a physician or nurse practitioner has prescribed tube feeding.
- Completed by
- Physician or NP (prescriber)
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 3224-67E
Application for Funding Hearing Devices
Demande de financement pour appareils auditifs
Asks for funding of FM systems, hearing aids, TTYs, and cochlear implant or BAHA processors, as prescribed by a physician or an audiologist.
- Completed by
- Prescriber (physician or audiologist) and ADP-registered authorizer; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 2451-67E
Application for Funding Home Oxygen Therapy
Demande de financement de l’oxygénothérapie à domicile
Requests funding for home oxygen, whether short-term, long-term for hypoxemia at rest or on exertion, or palliative, with oximetry or blood gas results attached.
- Completed by
- Physician or NP (prescription, oximetry/ABG results, signature); registered respiratory therapist or other regulated health professional (testing); vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4537-67E
Application for Funding Insulin Pumps and Supplies for Adults
Demande de financement pour pompes à insuline et fournitures pour adultes
Asks for funding of an insulin pump and its supplies for an adult living with diabetes, submitted together with a diabetes education program registered with the ADP.
- Completed by
- Physician or NP together with an ADP-registered diabetes education program; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4446-67E
Application for Funding Insulin Pumps and Supplies for Children
Demande de financement pour pompes à insuline et fournitures pour enfants
Asks for funding of an insulin pump and its supplies for a child living with diabetes, submitted through a paediatric diabetes education program registered with the ADP.
- Completed by
- Physician or NP together with an ADP-registered paediatric diabetes education program; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 3183-67E
Application for Funding Limb Prostheses
Demande de financement pour membre artificiel
Requests funding for an artificial limb and its components, with the physician's prescription and a prosthetist or other registered authorizer's assessment.
- Completed by
- Physician (prescription/signature) and ADP-registered authorizer/rehabilitation assessor (e.g., prosthetist); vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4821-67E
Application for Funding Maxillofacial Extraoral Prostheses
Demande de financement Prothèses maxillo-faciales extra-buccales
Requests funding for facial prostheses worn outside the mouth, prescribed by a physician and completed with a registered authorizer.
- Completed by
- Physician (prescriber; optometrist where applicable) and ADP-registered authorizer; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4820-67E
Application for Funding Maxillofacial Intraoral Prostheses
Demande de financement Prothèses maxillo-faciales intra-buccales
Requests funding for prostheses that replace tissue inside the mouth after loss or defect, prescribed by a physician or dentist.
- Completed by
- Prescriber (physician or dentist) and ADP-registered authorizer; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 2196-67E
Application for Funding Mobility Devices
Demande de financement pour aides à la mobilité
Requests funding for wheelchairs, scooters, positioning devices and walkers, and is completed by an authorizer registered for mobility devices.
- Completed by
- ADP-registered authorizer for mobility devices
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4658-67E
Application for Funding Ocular Prostheses
Demande de financement Prothèses oculaires
Requests funding for an artificial eye, prescribed by a physician or optometrist and confirmed by a registered authorizer.
- Completed by
- Prescriber (physician/optometrist) and ADP-registered authorizer; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4819-67E
Application for Funding Orthotic Devices
Demande de financement Orthèses
Requests funding for custom braces and other orthoses for a long-term physical disability, with the diagnosis confirmed and an authorizer completing the fitting side.
- Completed by
- Physician/NP or rehabilitation assessor (diagnosis/confirmation) and ADP-registered authorizer; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 1945-67E
Application for Funding Ostomy Grant
Demande de subvention pour stomisés
Applies for the yearly grant that helps a patient with a permanent ostomy pay for their supplies.
- Completed by
- Physician or NP
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4823-67E
Application for Funding Pressure Modification Devices
Demande de financement Dispositifs de modification de la tension
Requests funding for devices that relieve or redistribute pressure, using the physician or NP's diagnosis and a certified fitter's assessment.
- Completed by
- Physician or NP (diagnosis) and certified fitter/clinic; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- ON00323E
Application for Funding Real-Time Continuous Glucose Monitoring System (rtCGM)
Demande d'aide financière pour surveillance du glucose en continu (SGC) en temps réel
Asks for funding of a continuous glucose monitor that works in real time, and the physician or nurse practitioner confirms the patient meets the diabetes criteria.
- Completed by
- Physician or NP (eligibility); vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4792-67E
Application for Funding Ventilator Equipment and Supplies
Demande de financement Équipement et matériel pour ventilateur
Asks for funding of ventilator equipment and its supplies, and the prescribing physician completes and signs the application.
- Completed by
- Physician
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4824-67E
Application for Funding Visual Aids
Demande de financement Aides visuelles
Requests funding for visual aids for a patient with low vision, prescribed by a physician or optometrist.
- Completed by
- Prescriber (physician or optometrist) and ADP-registered authorizer; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 4521-84E
Application for Prior Approval for Full Payment of Insured Out-of-Country (OOC) & Out-of-Province (OOP) Laboratory & Genetics Testing
Demande d'approbation préalable du remboursement de services de santé hors pays/hors province assurés – Analyses de laboratoire et génétiques
Seeks advance approval for OHIP to fully pay for a lab or genetic test done outside Ontario because the test is not offered here.
- Completed by
- Practising Ontario physician (ordering), or the physician's office staff on their behalf
- Issued by
- Ministry of Health - OHIP
- Format
- Fillable PDF
- Language
- English and French
- 4768-69E
Health Assessment - Ontario Health atHome
Évaluation de l’état de santé – Santé à domicile Ontario
Documents the applicant's medical condition so placement co-ordinators can decide whether they qualify for admission to a long-term care home.
- Completed by
- Physician, RN(EC)/NP, or RN
- Issued by
- Ministry of Long-Term Care / Ontario Health atHome
- Format
- Fillable PDF
- Language
- English and French
- 3977-84E
Health Care Provider Claim - Diagnostic and Treatment Services for Uninsured Persons
Demande de règlement d'un fournisseur de soins de santé - Programme de diagnostic et de traitement pour les personnes non assurée
Lets a physician bill the province for diagnosing and treating tuberculosis in a patient who has no health insurance.
- Completed by
- Service provider (physician)
- Issued by
- Ministry of Health (public health - TB program)
- Format
- Fillable PDF
- Language
- English and French
- ON00509E
Inpatient Referral Form
Formulaire d’aiguillage pour patients hospitalisés
Refers a child or youth for inpatient services at CPRI, with the attending physician completing the medical part and the family or agency the rest.
- Completed by
- Attending physician (Part B); referring agency/family complete other parts
- Issued by
- CPRI (MCCSS)
- Format
- Fillable PDF
- Language
- English and French
-
Ontario Health atHome referral forms (by region)
Sends a patient to the regional home and community care service when they need nursing, therapy or personal support at home.
- Completed by
- Referring physician, NP or other provider
- Issued by
- Ontario Health atHome
- Format
- Language
- English
- 4882-83E
Oral and Maxillofacial Rehabilitation Program (OMRP) Application
Présentation d'une demande au Programme de réhabilitation orale et maxillo-faciale (PROM)
Refers an adult Ontario health card holder for an assessment by the rehabilitation program for oral and maxillofacial needs, where any prostheses are paid for through the ADP.
- Completed by
- Referring provider (e.g., physician, surgeon or dentist) for Sections 1-3; program clinicians complete the rest
- Issued by
- Ministry of Health (OMRP)
- Format
- Fillable PDF
- Language
- English and French
- 0000-80
Out of Province Claim for Physician Services
Réclamation hors province pour services médicaux
Lets an Ontario resident's care in another province be claimed back from OHIP when the treating physician did not bill through reciprocal billing.
- Completed by
- Treating (out-of-province) physician - Part C
- Issued by
- Ministry of Health - OHIP
- Format
- Fillable PDF
- Language
- English and French
- ON00510E
Outpatient Referral Form
Formulaire d’aiguillage pour patients en consultation externe
Refers a child or youth for outpatient services at CPRI, with the attending physician completing the medical part and the family or referrer the rest.
- Completed by
- Attending physician (Part B); referent/family complete other parts
- Issued by
- CPRI (MCCSS)
- Format
- Fillable PDF
- Language
- English and French
- 5023-67E
Power Dynamic Positioning Devices - Justification for Funding Chart
Dispositifs de positionnement dynamique électriques - Tableau justificatif pour financement
Explains why a patient needs power dynamic positioning devices, attached by the mobility authorizer to the main mobility funding application.
- Completed by
- ADP-registered authorizer (mobility)
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- ON00511E
Referral for Tertiary Medical Consultation Service
Aiguillage vers un service de consultation médicale tertiaire
A medical specialist uses this to refer a child or youth for a single consultation in developmental paediatrics or child psychiatry, which may include an autism diagnostic opinion.
- Completed by
- Referring medical specialist only (e.g., paediatrician, psychiatrist, neurologist, geneticist)
- Issued by
- CPRI (MCCSS)
- Format
- Fillable PDF
- Language
- English and French
-
Referral Form for Ontario Health atHome (Toronto Central)
Refers a patient in the Toronto Central region for home and community care, and the referral can come from a physician, NP or another provider.
- Completed by
- Referring physician or NP (referral source may be another provider)
- Issued by
- Ontario Health atHome
- Format
- Fillable PDF
- Language
- English
- 5037-67E
Renewal of Funding Home Oxygen Therapy
Renouvellement du financement de l'oxygénothérapie à domicile
Renews home oxygen funding when an approved period ends, with updated oximetry or an independent exercise assessment reviewed by a respirologist or internist.
- Completed by
- Physician/NP or regulated health professional (oximetry); respirologist/internist reviewing an Independent Exercise Assessment; vendor
- Issued by
- Ministry of Health - Assistive Devices Program (ADP)
- Format
- Fillable PDF
- Language
- English and French
- 2743-84
Request for Approval of Payment for Proposed Dental Procedures
Demande d'approbation du règlement d'honoraires pour actes bucco-dentaires proposés
Asks OHIP to approve dental or oral surgery that will be done in hospital, completed by the dentist with the attending physician's details.
- Completed by
- Dentist/oral surgeon (Part 1), with attending physician details
- Issued by
- Ministry of Health - OHIP
- Format
- Fillable PDF
- Language
- Bilingual
- 0691-84E
Request for Approval of Payment for Proposed Surgery
Demande d'approbation de reglement de frais d'actes chirurgicaux proposees
Gets payment approved before a surgeon performs an in-province procedure that OHIP only covers with prior approval.
- Completed by
- Surgeon
- Issued by
- Ministry of Health - OHIP
- Format
- Fillable PDF
- Language
- English and French
- 4347-84E
Request for Major Eye Examination
Demande d'examen complet de la vue
Recommends that a patient whose medical condition affects the eyes may have an insured major eye exam by a physician every 12 months.
- Completed by
- Physician or NP
- Issued by
- Ministry of Health - OHIP
- Format
- Fillable PDF
- Language
- English and French
- ON00314E
Request for Prior Approval for Full Payment of Insured Out-of-Country (OOC) Health Services
Demande d’approbation préalable du remboursement de services de santé hors pays assurés
Asks OHIP to approve in advance full payment for needed treatment outside Canada, when Ontario cannot provide it or the wait would harm the patient medically.
- Completed by
- Practising Ontario physician (referring)
- Issued by
- Ministry of Health - OHIP
- Format
- Fillable PDF
- Language
- English and French
- 4963-84E
Request for Prior Approval for Full Payment of Insured Out-of-Province (OOP) Health Services (in another province/territory)
Demande d'approbation préalable du remboursement de services de santé hors province assurés (autre province ou territoire)
Requests advance approval so that OHIP will pay in full for insured hospital or physician care in another province or territory that falls outside reciprocal billing.
- Completed by
- Attending or treating physician (referring Ontario physician section when one is involved)
- Issued by
- Ministry of Health - OHIP
- Format
- Fillable PDF
- Language
- English and French
- 5041-77E
Request for Prior Approval for Funding of Sex-Reassignment Surgery
Demande d'approbation préalable du remboursement d'un changement chirurgical de sexe
Asks for OHIP prior approval of insured gender-affirming surgery done in Ontario, in another part of Canada or abroad, backed by assessments from qualified providers trained by WPATH.
- Completed by
- Attending physician or NP (OOC requests also need Section 6 by a practising Ontario physician); supporting assessments by a physician, NP, registered psychologist or other qualified provider (WPATH-trained)
- Issued by
- Ministry of Health - OHIP
- Format
- Fillable PDF
- Language
- English and French
Other forms
-
Ontario's optional certificate for unpaid long-term illness leave under the Employment Standards Act. A physician, registered nurse or psychologist certifies a serious medical condition and the period off work.
- Completed by
- Physician, registered nurse (including nurse practitioner) or psychologist
- Issued by
- Ontario Ministry of Labour, Immigration, Training and Skills Development
- Format
- Fillable PDF
- Language
- English and French
-
Soins de santé primaires Déclaration d'un nouveau patient
Ontario Ministry of Health declaration signed when a new patient without a family physician enrols with a primary care physician. The patient completes Sections A to C and the physician signs Section D.
- Completed by
- Patient or substitute (Sections A to C); enrolling physician (Section D)
- Issued by
- Ontario Ministry of Health
- Format
- Fillable PDF
- Language
- English and French
- OCF-21
Auto Insurance Standard Invoice
Facture d’assurance-automobile standard
Bills the auto insurer for assessments, treatment and goods that were approved, with separate versions for minor injury and other claims.
- Completed by
- Health care provider or facility
- Issued by
- FSRA (Ontario SABS)
- Format
- Fillable PDF
- Language
- English and French
- 3261E
Invoice for Completing a Disability Determination Package, Medical Review Package or Providing Additional Medical Information
Facture pour remplir des documents de la Trousse de documents et formules sur la détermination de l'invalidité ou de la Trousse de révision de l'admissibilité sur le plan médical ou fournir des renseignements médicaux supplémentaires
Claims payment for completing ODSP disability forms, for health professionals not paid through OHIP, and for physicians supplying requested additional medical information.
- Completed by
- Health professionals not registered with OHIP (e.g., psychologists, optometrists, OTs, PTs, social workers, chiropractors); physicians only for requested Additional Medical Information
- Issued by
- ODSP (MCCSS) - Disability Adjudication Unit
- Format
- Fillable PDF
- Language
- English and French
- 3947A
Provider payment request
Demande de paiement du fournisseur
Bills the board on paper for health care services when electronic billing isn't used.
- Completed by
- Health care provider or clinic (billing)
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
Quebec
Workers' compensation
- 2001
Assignation temporaire d'un travail
Temporary Work Assignment
Gives the treating professional's view on a temporary work assignment the employer proposes, stating limitations and whether the work is reasonable, safe and favours rehabilitation.
- Completed by
- Treating health professional (professionnel de la santé qui a charge)
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 1936
Attestation médicale
Medical Certificate
Serves as the first medical certificate at the initial visit for a work accident, suspected occupational disease, recurrence, relapse or aggravation, recording diagnosis, injury sites, expected consolidation and care.
- Completed by
- First health professional consulted (professionnel de la santé): physician, IPS, dentist or optometrist
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 1166
Certificat visant l'affectation ou le retrait préventif de la travailleuse enceinte ou qui allaite
Certificate for Reassignment or Preventive Withdrawal of a Pregnant or Breastfeeding Worker
Certifies that a pregnant or nursing worker's job exposes the child or herself to physical hazards, which unlocks reassignment or preventive withdrawal under the safe maternity program.
- Completed by
- Professional following the pregnancy or postnatal care: physician, IPS or midwife (sage-femme)
- Issued by
- CNESST
- Format
- Sent for each case
- Language
- French
- 2271
Demande d'autorisation de traitement de physiothérapie – ergothérapie
Request for Treatment Authorization – Physiotherapy/Occupational Therapy
Asks the board to authorize physiotherapy or occupational therapy for a worker whose employment injury has recurred, relapsed or worsened.
- Completed by
- Physiotherapy/OT clinic (physiotherapist or occupational therapist)
- Issued by
- CNESST
- Format
- Language
- French
- OSI 6074
Demande d'autorisation pour la mise en place d'une mesure de réadaptation avant la consolidation de la lésion professionnelle
Request for Authorization to Implement a Rehabilitation Measure Before Consolidation of the Employment Injury
Seeks the treating professional's sign-off on rehabilitation before the injury is consolidated, for instance retraining, psychosocial services, a gradual return to tasks, or adapting a vehicle or workstation.
- Completed by
- Treating health professional (professionnel de la santé qui a charge)
- Issued by
- CNESST
- Format
- Sent for each case
- Language
- French
- 2096
Information médicale complémentaire écrite
Written Supplementary Medical Information
Answers a written request from a CNESST medical advisor to clarify a file, such as causal relationship, consolidation period, limitations or a pre-existing condition.
- Completed by
- Treating health professional (professionnel de la santé qui a charge)
- Issued by
- CNESST
- Format
- Sent for each case
- Language
- French
- 2349
Rapport complémentaire
Supplementary Report
Used by the treating professional to defend their findings if the employer's or board's appointed professional takes a different view, before the medical evaluation bureau reviews it.
- Completed by
- Treating health professional (professionnel de la santé qui a charge)
- Issued by
- CNESST
- Format
- Sent for each case
- Language
- French
- 5054
Rapport d'ergothérapie
Occupational Therapy Report
Reports on a worker treated by an occupational therapist after an employment injury, covering health status, problems found, the treatment plan and return-to-work arrangements.
- Completed by
- Occupational therapist (ergothérapeute)
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 1844
Rapport d'évaluation – Intervention psychosociale en réadaptation
Evaluation Report – Psychosocial Intervention in Rehabilitation
Assesses what psychosocial help an injured worker needs, under a services contract, where personal difficulties from the injury block social or occupational recovery.
- Completed by
- Professional providing psychosocial rehabilitation services under a CNESST contract (listed under psychologists/psychotherapists; has a neuropsychological evaluation section)
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 2064
Rapport d'évaluation médicale
Medical Evaluation Report
Assesses a worker after consolidation across 12 points, from diagnosis and history to permanent functional limitations, with sequelae given as codes and percentages.
- Completed by
- Treating health professional (physician; CNESST says an IPS may assess permanent impairment and limitations) or the professional the worker was referred to
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 5005-R
Rapport d'évaluation psychologique, psychothérapeutique ou neuropsychologique
Psychological, Psychotherapeutic or Neuropsychological Evaluation Report
Sets out a first evaluation after referral by prescription: history, what affects function and return to work, how the worker perceives things, and a treatment plan.
- Completed by
- Psychologist, psychotherapist or neuropsychologist
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 5006-R
Rapport d'évolution – intervention psychologique, psychothérapeutique ou neuropsychologique
Progress Report – Psychological, Psychotherapeutic or Neuropsychological Intervention
Tracks an injured worker's progress while receiving psychological, psychotherapy or neuropsychology treatment.
- Completed by
- Psychologist, psychotherapist or neuropsychologist
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 1845
Rapport d'évolution ou rapport final – Intervention psychosociale en réadaptation
Progress Report or Final Report – Psychosocial Intervention in Rehabilitation
Gives a progress update or closing report on psychosocial rehabilitation delivered at the board's request.
- Completed by
- Professional providing psychosocial rehabilitation services under a CNESST contract
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 5053
Rapport de physiothérapie
Physiotherapy Report
Describes a worker's physiotherapy, prescribed by the treating professional, including health status during treatment, problems identified and the plan going forward.
- Completed by
- Physiotherapist
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 1938
Rapport final
Final Report
Closes the file at consolidation with the final diagnosis and date, any permanent impairment or functional limitations, and whether the treating professional will do the medical assessment report.
- Completed by
- Treating health professional (professionnel de la santé qui a charge): physician or IPS
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 5007-R
Rapport final - intervention psychologique, psychothérapeutique ou neuropsychologique
Final Report – Psychological, Psychotherapeutic or Neuropsychological Intervention
Wraps up an injured worker's psychological, psychotherapeutic or neuropsychological treatment with an end-of-intervention report.
- Completed by
- Psychologist, psychotherapist or neuropsychologist
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 1937
Rapport médical
Medical Report (initial-care summary or progress report)
Reports on an employment injury from the treating professional, as a care summary when consolidation is expected after more than 14 days or when care changes significantly.
- Completed by
- Treating health professional (professionnel de la santé qui a charge): physician or IPS; dentist or optometrist within their scope
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
Insurance claims
- 4068
After-Effects Report and Receipt or Invoice for a Report
Rapport sur les séquelles et reçu ou facture
Assesses whether injuries from a road accident have left permanent after-effects, when the SAAQ asks for it.
- Completed by
- Physician or IPS
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- English and French
- 7012
Aide personnelle – Grille à l'usage des ergothérapeutes
Personal Assistance – Grid for Occupational Therapists
An occupational therapist records the personal assistance a road accident victim needs, and the SAAQ relies on this to set the indemnity.
- Completed by
- Occupational therapist
- Issued by
- SAAQ
- Format
- Language
- French
- 4066
Assessment Report and Receipt or Invoice for a Report
Rapport d'évaluation et reçu ou facture
Reports on the overall health of a road accident victim when the SAAQ requests it, at times on a pre-identified form that the SAAQ sends.
- Completed by
- Physician or IPS
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- English and French
-
Attending Physician’s Questionnaire – Mental Health Conditions
Gathers the attending physician's information on a mental health condition when a patient files a disability claim.
- Completed by
- Attending physician
- Issued by
- Blue Cross Ontario & Québec (Canassurance)
- Format
- Fillable PDF
- Language
- English
-
Attending Physician’s Statement - Short Term Disability Claim
Provides the insurer with the physician's or nurse practitioner's description of the patient's condition to support a claim for short-term disability.
- Completed by
- Physician (or nurse practitioner where applicable)
- Issued by
- Blue Cross Ontario & Québec (Canassurance)
- Format
- Fillable PDF
- Language
- English
- 7484
Complementary Medical Information – Disability
Information médicale complémentaire – Incapacité
Provides additional medical detail about the functional limitations and work capacity of a road accident victim, whenever the SAAQ requests it.
- Completed by
- Physician or IPS
- Issued by
- SAAQ
- Format
- Language
- English and French
-
Critical Illness Claim Form
Collects the claimant's statement, the attending physician's statement and a medical certificate for a critical illness claim.
- Completed by
- Attending physician
- Issued by
- Blue Cross Ontario & Québec (Canassurance)
- Format
- Language
- English
- 5695
Demande de remboursement de frais de physiothérapie
Request for Reimbursement of Physiotherapy Costs
Allows physiotherapy clinics in private practice to send the SAAQ a bill for the treatments given to a road accident victim.
- Completed by
- Physiotherapist / physiotherapy clinic
- Issued by
- SAAQ
- Format
- Language
- French
- 5696
Demande de remboursement de frais de psychologie
Request for Reimbursement of Psychology Fees
Allows psychologists and psychotherapists in private practice to send the SAAQ a bill for the treatments given to a road accident victim.
- Completed by
- Psychologist or psychotherapist
- Issued by
- SAAQ
- Format
- Language
- French
- 4065
Initial Report and Invoice for an Initial Report
Rapport initial et facture
Starts a road accident victim's SAAQ compensation file with the first medical report, completed at the first consultation and paired with the clinician's invoice.
- Completed by
- Physician or specialized nurse practitioner (IPS)
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- English and French
- 4300-021
Maladie à caractère physique – Rapport supplémentaire
Updates the insurer on a continuing disability claim caused by a physical illness.
- Completed by
- Attending physician
- Issued by
- Humania
- Format
- Fillable PDF
- Language
- French
- 4300-021
Maladie à caractère psychologique – Rapport supplémentaire
Updates the insurer on a continuing disability claim caused by a psychological illness.
- Completed by
- Attending physician
- Issued by
- Humania
- Format
- Language
- French
-
Maladies graves – Déclaration du médecin (condition-specific)
Maladies graves – Déclaration du médecin
Gives the physician's statement for a critical illness claim, with a separate version for each condition.
- Completed by
- Attending physician
- Issued by
- Humania
- Format
- Language
- French
- 4300-016
Preuves de décès – Déclaration du médecin
Gives the physician's statement for a life insurance claim after a death.
- Completed by
- Attending physician
- Issued by
- Humania
- Format
- Language
- French
- 4067
Progress Report and Receipt or Invoice for a Report
Rapport d'évolution et reçu ou facture
Reports a road accident victim's progress when the SAAQ requests it, for example if recovery departs from what was expected.
- Completed by
- Physician or IPS
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- English and French
- 4056
Rapport d'évolution en physiothérapie et facture
Physiotherapy Progress Report and Invoice
Justifies physiotherapy beyond the reimbursable limit for a road accident victim, due at the 15th treatment or ninth week and again at the 35th treatment.
- Completed by
- Physiotherapist
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- French
- 4780
Rapport du dentiste
Dentist's Report
Describes the damage to the teeth from a road accident, in support of the victim's claim to the SAAQ.
- Completed by
- Dentist
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- French
- 4054
Résumé d'évaluation finale – Traitement de psychologie
Final Assessment Summary – Psychological Treatment
Summarizes how psychological treatment ended for a road accident victim, and is completed when the work with the psychologist or psychotherapist is over.
- Completed by
- Psychologist or psychotherapist in private practice
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- French
- 4052
Résumé d'évaluation initiale – Traitement de psychologie
Initial Assessment Summary – Psychological Treatment
At the first checkpoint (balise 1), gets a road accident victim's first psychological evaluation reimbursed and the hours of treatment approved.
- Completed by
- Psychologist or psychotherapist in private practice
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- French
-
Status Update - Confirmation of Ongoing Long Term Disability
Updates the insurer on whether a patient's long-term disability is continuing, written by the attending physician or NP.
- Completed by
- Attending physician (or nurse practitioner where applicable)
- Issued by
- Blue Cross Ontario & Québec (Canassurance)
- Format
- Fillable PDF
- Language
- English
- 4053
Suivi et résumé d'évolution – Traitement de psychologie
Follow-up and Progress Summary – Psychological Treatment
Requests more psychology reimbursement for a road accident victim once the 12th or 27th treatment hour is reached (balises 2 and 3).
- Completed by
- Psychologist or psychotherapist in private practice
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- French
Government benefits and tax credits
- LPF-825
Application for the Supplement for Handicapped Children – Professional's Part
Demande de supplément pour enfant handicapé – Partie de la professionnelle ou du professionnel
Supplies the clinical part of an application for the supplement paid with the family allowance, assessing a child under 18 with an impairment that greatly limits daily life.
- Completed by
- Health professional who knows the child best, is a member of a professional order and assessed or saw the child in the last 12 months (physician, psychologist, speech-language pathologist, OT, physiotherapist, audiologist, optometrist, etc.)
- Issued by
- Retraite Québec
- Format
- Fillable PDF
- Language
- English and French
- 280
Attestation d'un intervenant ou d'un professionnel
Attestation by a Support Worker or Professional (IVAC)
Attests that a victim disclosed the criminal offence, with its description, date and place, and is one accepted way to supply the mandatory document with a compensation request.
- Completed by
- Victim-support worker, police, legal worker or health professional (member of a professional order)
- Issued by
- CNESST – IVAC
- Format
- Fillable PDF
- Language
- French
- 227
Attestation médicale
Medical Certificate (IVAC)
Opens the medical file for someone hurt by a crime or while rescuing another person, covering diagnosis, expected consolidation, usual activities, follow-up and referrals.
- Completed by
- Physician (first consulted); IVAC says IPS also complete its medical forms
- Issued by
- CNESST – IVAC
- Format
- Fillable PDF
- Language
- French
- SR-0040
Certificat médical
Medical Certificate
Certifies, for last-resort assistance recipients, pregnancy and prenatal or postnatal transport needs, and requests special benefits like prostheses, orthopedic shoes or home hemodialysis.
- Completed by
- Physician, IPS or midwife (pregnancy and prenatal/postnatal transport); physician, dentist or IPS (special medical benefits)
- Issued by
- MESS
- Format
- Fillable PDF
- Language
- French
- 1015
Certificat médical – Personne aux études – Déficience entraînant une incapacité significative et persistante
Medical Certificate – Student with an Impairment Causing a Significant and Persistent Disability (Major Functional Deficiencies)
Certifies the impairment of a student and how long its effects last, so they can receive accommodations from Quebec student aid or join the special needs allowance program.
- Completed by
- Physician (Section 2, diagnosis); Section 3 by a physician or another professional under the Professional Code with the needed skills (e.g. psychologist or mental-health IPS for mental functions, optometrist for vision)
- Issued by
- AFE
- Format
- Language
- French
- TP-1029.AN.A
Certificate of Ongoing Assistance
Attestation d'assistance soutenue
Certifies, for the caregiver credit, that a caregiver without a family tie to the person receiving care gives continuing help with a basic daily activity.
- Completed by
- Professional of the health and social services network (RSSS), or a private-sector professional (member of a professional order) mandated by the RSSS to serve the care recipient
- Issued by
- Revenu Québec
- Format
- Fillable PDF
- Language
- English and French
- TP-752.0.14
Certificate Respecting an Impairment
Attestation de déficience
Certifies that someone aged 18 or older has a severe, prolonged impairment of mental or physical function, supporting the disability amount, enhanced childcare or activity credits, or the caregiver credit.
- Completed by
- Physician, specialized nurse practitioner, optometrist, audiologist, speech-language pathologist, occupational therapist, psychologist or physiotherapist (each within their field)
- Issued by
- Revenu Québec
- Format
- Fillable PDF
- Language
- English and French
- TP-1029.8.66.2M
Certificate Respecting the Treatment of Infertility
Attestation relative au traitement de l'infertilité
Supports the refundable tax credit for infertility treatment, or its advance payment, with the treating physician answering questions such as whether equivalent treatment exists within 200 km.
- Completed by
- Treating physician of the person undergoing treatment
- Issued by
- Revenu Québec
- Format
- Fillable PDF
- Language
- English and French
- TPZ-1029.MD.A
Certification of Dependent Senior Status - Tax Credit for Home-Support Services for Seniors
Attestation – Statut de personne non autonome – Crédit d'impôt pour maintien à domicile des aînés
Confirms that a senior claiming the credit for help at home is dependent, meaning they always need help with personal care or constant supervision due to a serious mental disorder.
- Completed by
- Physician or specialized nurse practitioner
- Issued by
- Revenu Québec
- Format
- Fillable PDF
- Language
- English and French
- TP-752.0.13.1
Expenses for Medical Services Not Available in Your Area
Frais pour soins médicaux non dispensés dans votre région
Supports a credit claim covering the cost of travel, lodging or moving to get care in Quebec not available within 200 km, with the clinician certifying local care was lacking.
- Completed by
- Treating physician or specialized nurse practitioner
- Issued by
- Revenu Québec
- Format
- Fillable PDF
- Language
- English and French
- B-076
Medical Report - Québec Pension Plan
Rapport médical – Régime de rentes du Québec
Details the health of someone applying for disability benefits under the Québec Pension Plan, or being re-assessed medically for them.
- Completed by
- Physician
- Issued by
- Retraite Québec
- Format
- Fillable PDF
- Language
- English and French
- RSP-448
Medical Report for Disability Benefits in the Case of Terminal Illness Under a Public-Sector Pension Plan
Rapport médical pour une prestation de maladie en phase terminale d'un régime de retraite du secteur public
Backs a claim for a benefit on account of a terminal illness under a public-sector pension plan in Quebec.
- Completed by
- Physician (implied by the title; the page does not specify)
- Issued by
- Retraite Québec
- Format
- Language
- English and French
- RSP-502
Medical Report for Disability Benefits Under a Public-Sector Pension Plan
Rapport médical pour une prestation d'invalidité d'un régime de retraite du secteur public
Backs a claim for a disability benefit under a Quebec pension plan for the public sector, such as RREGOP or PPMP.
- Completed by
- Physician (implied by the title; the page does not specify)
- Issued by
- Retraite Québec
- Format
- Language
- English and French
- 257
Rapport d'évaluation initiale – Réhabilitation psychothérapique ou psychosociale
Initial Evaluation Report – Psychotherapeutic or Psychosocial Rehabilitation (IVAC)
Gives the program a broad picture of the person's circumstances tied to the offence or rescue the program accepted, written after a few therapy sessions.
- Completed by
- Psychologist, psychotherapist (permit holder) or professional authorized for psychosocial follow-up (IVAC-registered provider)
- Issued by
- CNESST – IVAC
- Format
- Word document
- Language
- French
- SR-2100
Rapport d'évaluation médicale ou psychosociale
Medical or Psychosocial Assessment Report
Records a diagnosis along with temporary, prolonged or permanent limitations, letting the ministry accept that health problems create barriers to employment for last-resort financial assistance.
- Completed by
- Physician, specialized nurse practitioner, psychologist, social worker, or couple and family therapist
- Issued by
- MESS
- Format
- Fillable PDF
- Language
- French
- 256
Rapport d'évolution – Réhabilitation psychothérapique ou psychosociale
Progress Report – Psychotherapeutic or Psychosocial Rehabilitation (IVAC)
Reports on psychotherapeutic or psychosocial rehabilitation progress, with recommendations the program uses to justify continued funding.
- Completed by
- Psychologist, psychotherapist or professional authorized for psychosocial follow-up (IVAC-registered provider)
- Issued by
- CNESST – IVAC
- Format
- Word document
- Language
- French
- 229
Rapport final
Final Report (IVAC)
States the date the injury of a crime victim or rescuer consolidated, notes any lasting sequelae or limits, and this in turn triggers a medical assessment report (REM).
- Completed by
- Physician providing medical follow-up (or IPS)
- Issued by
- CNESST – IVAC
- Format
- Fillable PDF
- Language
- French
- 259
Rapport final – Réhabilitation psychothérapique ou psychosociale
Final Report – Psychotherapeutic or Psychosocial Rehabilitation (IVAC)
Concludes rehabilitation follow-up with findings, the person's own view, outcomes against goals and why it ended; it may support a lump-sum claim once no meaningful improvement is expected.
- Completed by
- Psychologist, psychotherapist or professional authorized for psychosocial follow-up (IVAC-registered provider)
- Issued by
- CNESST – IVAC
- Format
- Word document
- Language
- French
- 228
Rapport médical
Medical Report (IVAC)
Updates the file on a crime victim or rescuer under the physician's follow-up, produced whenever the type or length of care shifts significantly.
- Completed by
- Physician providing medical follow-up (or IPS)
- Issued by
- CNESST – IVAC
- Format
- Fillable PDF
- Language
- French
- LPF-630 series
Reassessment report of the various medical conditions for the eligibility for the Supplement for Handicapped Children (4 forms)
Rapports de réévaluation des différentes conditions médicales pour l'admissibilité au SEH
Re-assesses whether a child still qualifies for the supplement for handicapped children, through four condition-specific reports covering physical impairments, food allergies, hearing and mental function.
- Completed by
- Health professional (member of a professional order who assessed or saw the child in the last 12 months)
- Issued by
- Retraite Québec
- Format
- Language
- English and French
Drug coverage
- 3633
Demande d'autorisation de paiement – Médicament d'exception
Request for Payment Authorization – Exception Drug
Seeks public plan payment for an exception drug in Quebec when the drug has no code or no existing code suits the patient.
- Completed by
- Authorized prescriber (physician, IPS or other authorized prescriber)
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 3996
Demande d'autorisation de paiement – Mesure du patient d'exception
Request for Payment Authorization – Exceptional Patient Measure
Seeks public plan payment under the exceptional patient measure for a drug absent from the list, or an exception drug used for an unlisted indication.
- Completed by
- Authorized prescriber
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 4515
Demande d'autorisation de paiement (hors Québec) – Médicament d'exception
Request for Payment Authorization (Outside Québec) – Exception Drug
Makes the exception drug payment request for prescribers practising outside Quebec who haven't joined the provincial health insurance plan; the Quebec version is form 3633.
- Completed by
- Out-of-Québec prescriber
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 4516
Demande d'autorisation de paiement (hors Québec) – Mesure du patient d'exception
Request for Payment Authorization (Outside Québec) – Exceptional Patient Measure
Makes the exceptional patient measure request for prescribers practising outside Quebec who haven't joined the provincial health insurance plan; the Quebec version is form 3996.
- Completed by
- Out-of-Québec prescriber
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 8500
Demande d'exemption du prix maximum payable (PMP) – Nexium (Esoméprazole), Prevacid FasTab (Lansoprazole)
Request for Exemption from the Maximum Payable Price (MPP) – Nexium (esomeprazole), Prevacid FasTab (lansoprazole)
Seeks relief from the maximum price payable so the public plan will pay for Nexium or Prevacid FasTab for a particular patient.
- Completed by
- Prescriber
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 4596
Demande de remboursement exceptionnel du coût d'un médicament innovateur
Request for Exceptional Reimbursement of the Cost of an Innovator Drug
Asks RAMQ to reimburse the brand-name innovator drug when the insured has medical reasons to take it, documenting consequences such as hospitalization, emergency care or lasting disability.
- Completed by
- Prescriber
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- M6453
Quebec Exception Patient Program Form
Assesses a drug claim for a Quebec plan member who qualifies through the provincial exception patient program run by RAMQ.
- Completed by
- Prescribing physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
- M6453
Quebec Exceptional Medications Form
Assesses a drug claim for a Quebec plan member prescribed a medication that RAMQ places on its exceptional list.
- Completed by
- Prescribing physician
- Issued by
- Canada Life
- Format
- Fillable PDF
- Language
- English
Driving and licensing
- 5626
Declaration of Unfitness to Drive a Motor Vehicle
Déclaration d'inaptitude à conduire un véhicule routier
Allows a health professional to notify the licensing agency that a patient is unfit to drive.
- Completed by
- Health professional who judges the patient unfit to drive
- Issued by
- SAAQ
- Format
- Language
- English and French
- 6205
Eye Examination Report – Ophthalmology/Optometry – Eye Health – Fitness to Drive (5)
Rapport d'examen visuel en ophtalmologie ou en optométrie – Santé visuelle – Aptitude à conduire
Reports eye exam findings, such as acuity and visual field, so the licensing agency can judge if a driver meets vision standards.
- Completed by
- Optometrist or ophthalmologist
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- English and French
- 5790
Functional Assessment Report on Physical and Mental Fitness to Drive (57)
Rapport d'évaluation fonctionnelle sur l'aptitude physique et mentale à conduire un véhicule routier
Evaluates how well a driver's body and mind cope with driving, including an on-road test, when the licensing agency asks an occupational therapist to assess.
- Completed by
- Occupational therapist (driving evaluator)
- Issued by
- SAAQ
- Format
- Language
- English and French
- 6211
Medical Cardiovascular Examination Report (11)
Rapport d'examen médical cardiovasculaire – Permis de conduire
Reports a cardiovascular examination the licensing agency requests when assessing whether someone is fit to drive.
- Completed by
- Physician
- Issued by
- SAAQ
- Format
- Language
- English and French
- 5903
Medical Examination Report on a Diabetic Person's Fitness to Safely Operate a Motor Vehicle (90)
Rapport d'évaluation médicale sur l'aptitude à la conduite sécuritaire d'un véhicule routier en présence d'un diabète
Evaluates a driver with diabetes, including the risk of hypoglycemia, when the licensing agency asks for a medical opinion.
- Completed by
- Physician (or other treating professional; not specified on the page)
- Issued by
- SAAQ
- Format
- Language
- English and French
- 6214
Medical Neurological Examination Report (14)
Rapport d'examen médical neurologique
Reports a neurological examination, for example for seizures, stroke or neurodegenerative disease, that the licensing agency requests to assess fitness to drive.
- Completed by
- Physician
- Issued by
- SAAQ
- Format
- Language
- English and French
- 6218
Medical Otorhinolaryngological Examination Report (18)
Rapport d'examen médical oto-rhino-laryngologique – Permis de conduire
Reports an ear, nose and throat examination covering hearing and vestibular function that the licensing agency requests to assess fitness to drive.
- Completed by
- Physician
- Issued by
- SAAQ
- Format
- Language
- English and French
- 6213
Medical Psychiatric Examination Report (13)
Rapport d'examen médical psychiatrique
Reports a psychiatric examination the licensing agency requests when assessing whether someone is fit to drive.
- Completed by
- Physician
- Issued by
- SAAQ
- Format
- Language
- English and French
- 6228
Report on a Person's State of Health (28)
Rapport sur l'état de santé – Permis de conduire
General medical report requested to judge whether a licence holder or applicant can drive safely, with sections spanning vision, hearing, neurological, heart, lung and other conditions.
- Completed by
- Health professional (usually the treating physician)
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- English and French
- 5890
Road Test Report by an Occupational Therapist (58)
Rapport du test routier effectué par un ergothérapeute
Records what an occupational therapist observed during an on-road driving test done for the licensing agency.
- Completed by
- Occupational therapist
- Issued by
- SAAQ
- Format
- Language
- English and French
Mental health and medico-legal
-
Evaluator notices for tutorship reassessment (3 forms)
Avis ou rapport de l'évaluateur ou de l'évaluatrice – réévaluation d'une tutelle (maintien; modification du délai; modification ou fin)
Gives the evaluator's brief notice at the periodic review of an adult tutorship: keep it, change only the review date, or modify or end it.
- Completed by
- Evaluator (physician or psychosocial evaluator; profession not specified)
- Issued by
- Curateur public
- Format
- Language
- English and French
-
Medical assessment (temporary representation)
Évaluation médicale – Représentation temporaire
Backs a court request for a relative or designated professional to temporarily represent an adult who is unable to act for themselves.
- Completed by
- Physician
- Issued by
- Curateur public
- Format
- Language
- English and French
-
Medical assessment (tutorship to a person of full age or homologation of a protection mandate)
Évaluation médicale dans le cadre de l'ouverture d'une tutelle au majeur ou de l'homologation d'un mandat de protection
Assesses an adult's faculties for the court, either to open a tutorship or to homologate (activate) a protection mandate.
- Completed by
- Physician (médecin-évaluateur)
- Issued by
- Curateur public
- Format
- Fillable PDF
- Language
- English and French
-
Medical reassessment (tutorship)
Réévaluation médicale dans le cadre d'une tutelle
Backs a recommendation to alter the nature or modulation of tutorship over an adult, or to bring it to an end.
- Completed by
- Physician
- Issued by
- Curateur public
- Format
- Language
- English and French
-
Psychosocial assessment forms (tutorship, mandate homologation, temporary representation, reassessment)
Évaluation psychosociale (tutelle; homologation d'un mandat; représentation temporaire) et Réévaluation psychosociale dans le cadre d'une tutelle
Accompanies the medical assessment when a protective measure is opened or reviewed, completed by a social worker or other authorized professional.
- Completed by
- Social worker or other professional authorized under the Professional Code (mandatory training)
- Issued by
- Curateur public
- Format
- Language
- English and French
- 025-DGSP-2019-01
Request for consent to care (also: to a level of care/goals of care, to control measures) – person represented by the Curateur public
Demande de consentement à un soin (aussi : à un niveau de soin ou objectif de soins; à des mesures de contrôle)
Asks the Curateur public, acting as legal representative, to consent on behalf of a person who cannot consent to care, to a particular level of care or to control measures.
- Completed by
- Professional proposing the care, who assesses the person's capacity to consent; signed by the physician
- Issued by
- Curateur public
- Format
- Fillable PDF
- Language
- English and French
Parking, transit and travel
- 6375
Accessible Parking Permit Application
Demande de vignette de stationnement pour personnes handicapées
Requests a disability parking permit and, where an evaluation is required, records diagnoses, impairments, functional class, how long and what kind of incapacity exists, and mobility lost outdoors.
- Completed by
- Professional listed in Section E: physician, nurse, occupational therapist, optometrist, physiotherapist, physiotherapy technologist, psychologist, chiropractor, respiratory therapist, podiatrist, psychoeducator, specialized educator (health network), orientation & mobility specialist or social worker
- Issued by
- SAAQ
- Format
- Fillable PDF
- Language
- English and French
- V-2851
Demande d'admission au transport adapté
Attests to disabilities and limited mobility for admission to Montreal paratransit on Quebec's provincial form, and the type of disability decides which professional completes it.
- Completed by
- Health- or school-network professional with access to the diagnosis, by disability type: OT, PT or physical rehabilitation therapist (motor/organic); specialist, OT or PT (cardiac, pulmonary, Parkinson's, Alzheimer's, TBI); special educator, adapted-school teacher, psychoeducator or social worker (intellectual disability/ASD); optometrist or orientation-and-mobility/visual rehab specialist (visual); OT or mental-health worker (psychiatric)
- Issued by
- STM (Ministère des Transports du Québec provincial form)
- Format
- Language
- French
-
Demande d'admission transport adapté
A professional in health, education or social services attests to what the applicant cannot do, in support of admission to the STAC paratransit service in Quebec City.
- Completed by
- Health care, education or social service professional (RTC publishes a guide for these professionals)
- Issued by
- RTC (Réseau de transport de la Capitale) - STAC
- Language
- French
Health programs
- 3841
Attestation du besoin d'une aide à la locomotion ou à la posture
Certification of Need for a Mobility or Posture Aid
Supports a request for a wheelchair, stroller, positioning base or posture aid, using a functional evaluation by an occupational therapist or physiotherapist that the prescribing physician signs.
- Completed by
- Occupational therapist or physiotherapist (evaluation) plus the authorized prescribing physician (signature)
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 3486
Certificat médical – Programme d'aides auditives
Medical Certificate – Hearing Aids Program
An ENT specialist certifies what type of hearing loss each ear has and whether it is permanent, lists any contraindications, and states whether a device is needed.
- Completed by
- Otolaryngologist (ENT)
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 4086
Certificat médical pour l'exemption de photo ou de signature
Medical Certificate for Exemption from Photo or Signature – Health Insurance Card
States that because of an illness or impairment a person cannot have their photo taken or sign, so that a Quebec health card can be issued anyway.
- Completed by
- Physician
- Issued by
- RAMQ
- Format
- Language
- French
- 4248
Demande d'autorisation en plastie
Request for Authorization – Plastic Surgery
Asks for authorization so a plastic surgery procedure, such as scar correction or breast surgery, is paid as an insured service.
- Completed by
- Surgeon (the physician providing the service)
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 4306
Demande d'autorisation préalable pour l'obtention de services médicaux hors du Québec
Request for Prior Authorization to Obtain Medical Services Outside Québec
Asks for prior authorization of medical or hospital care that a patient will get outside Quebec, signed by two physicians familiar with the disease.
- Completed by
- Two requesting physicians with expertise in the patient's disease (both sign)
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 3497
Ordonnance médicale – Orthèses, prothèses, aides à la locomotion, aides à la posture
Medical Prescription – Orthoses, Prostheses, Mobility Aids, Posture Aids
Prescribes orthoses, prostheses, orthopedic devices, and mobility or posture aids, stating the diagnosis, the incapacity and how long the device is medically required.
- Completed by
- Authorized prescriber (GP, specialist or IPS; certain aids need specific specialists)
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
- 3485
Recommandation – Aide de suppléance à l'audition
Recommendation – Assistive Listening Device
Recommends assistive listening or alerting devices for text, sound transmission or environmental alerts for a person covered by the provincial hearing aids program.
- Completed by
- Audiologist
- Issued by
- RAMQ
- Format
- Fillable PDF
- Language
- French
Other forms
- 1904
Bordereau de transmission – Frais de médicaments prophylactiques
Transmittal Slip – Prophylactic Medication Costs (IVAC)
Serves as the fax cover a pharmacy sends to be reimbursed for preventive medication it dispensed to a crime victim.
- Completed by
- Pharmacy/pharmacist (pharmacy and supplier information); the claimant signs
- Issued by
- CNESST – IVAC
- Format
- Fillable PDF
- Language
- French
- 258
Compte de services d'intervention psychothérapique ou psychosociale
Statement of Account for Psychotherapeutic or Psychosocial Intervention Services (IVAC)
Invoices for therapy visits with a victim of crime or a rescuer, itemizing dates, the initial evaluation, the intervention and totals.
- Completed by
- Psychologist, psychotherapist or psychosocial professional (IVAC-registered provider)
- Issued by
- CNESST – IVAC
- Format
- Fillable PDF
- Language
- French
- 5055
Compte de soins et traitements de physiothérapie ou d'ergothérapie
Statement of Account for Physiotherapy or Occupational Therapy Care and Treatment
Bills for physiotherapy or occupational therapy given to an injured worker and records attendance, sent after the first evaluation and again at the end of treatment.
- Completed by
- Physiotherapist, physiotherapy technologist (T.R.P.) or occupational therapist (clinic)
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
- 5008
Compte de soins ou de services de psychologie ou de psychothérapie
Statement of Account for Psychology or Psychotherapy Care or Services
Invoices the board for psychology, psychotherapy or neuropsychology given to an injured worker, and must come with the shared information page for every evaluation, progress and final report.
- Completed by
- Psychologist, psychotherapist or neuropsychologist
- Issued by
- CNESST
- Format
- Fillable PDF
- Language
- French
New Brunswick
Workers' compensation
-
Audiometric Report
Rapport audiometrique
Supplies the audiogram and hearing findings that back a worker's occupational hearing loss claim.
- Completed by
- Audiologist
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
- 8-10
Chiropractic Form 8-10
Formulaire 8-10 – Rapport du chiropraticien
Combines the chiropractor's first report on a work accident or occupational disease with the later progress report.
- Completed by
- Chiropractor
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
-
Estimate of Required Dental Services
Coût estimatif des services dentaires requis
Charts the affected teeth and estimates the cost of care required after a dental injury at work.
- Completed by
- Dentist or denturist
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
- 33
Form 33 – Claimant Prescription Information
Formulaire 33 – Détails de l'ordonnance
Itemizes the prescriptions a pharmacy dispensed for a claim, with drug identification numbers, quantities and charges, so the pharmacy is paid directly or the claimant is reimbursed.
- Completed by
- Pharmacist/pharmacy (supplier); claimant signs
- Issued by
- WorkSafeNB
- Format
- Language
- English and French
- HA-01
Form HA-01 – Hearing Aid Fitting and Service Report
Formulaire HA-01 – Rapport sur l'ajustement et le service relatifs à un appareil auditif
Records a hearing aid fitting for a claimant, whether the device is standard or an exception, with supplies and service, and can confirm the visit for mileage.
- Completed by
- Audiologist (hearing aid service provider)
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
- HA-02
Form HA-02 – Exception Report
Formulaire HA-02 – Rapport d'exception
Justifies replacing a claimant's hearing aid with a non-standard model that falls outside the board's standing-offer device list.
- Completed by
- Audiologist (hearing aid service provider)
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
-
Initial Psychology Assessment Report
Service psychologique – Rapport d'évaluation initiale
Reports a mental health provider's first assessment of an injured worker; treatment should wait until the board approves it.
- Completed by
- Psychologist, social worker or counselling therapist
- Issued by
- WorkSafeNB
- Format
- Word document
- Language
- English and French
-
Ketamine Review
Examen de la thérapie par la kétamine
Seeks approval for ketamine or esketamine treatment on a claim, then documents periodic reviews of how treatment is going.
- Completed by
- Treating physician/treatment provider
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
- 8-10
Medical Form 8-10
Formulaire médical 8-10
Reports a worker's accident or occupational disease at the first visit and again at progress visits, all on one form.
- Completed by
- Physician or NP
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
-
Mental Health Provider Report
Rapport d'évolution en psychologie santé mentale
Covers a worker's mental health treatment from start to finish, with initial, progress and discharge versions on set timelines.
- Completed by
- Psychologist (LPsych), counselling therapist (LCT) or social worker (MSW)
- Issued by
- WorkSafeNB
- Format
- Word document
- Language
- English and French
-
Physiotherapy Progress Report
Rapport d'évolution en physiothérapie
Updates the case manager on a worker's physiotherapy, covering symptoms, objective and neurological findings, range of motion, treatment and goals.
- Completed by
- Physiotherapist
- Issued by
- WorkSafeNB
- Format
- Language
- English and French
-
Psychology Discharge Report
Service psychologique – Résumé de dossier
Closes out a worker's psychology care by listing treatments given, missed appointments, the rehabilitation goal and where the patient goes next.
- Completed by
- Psychologist/therapist
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
-
Referral Service Form WRC
Client adressé pour une admission au Centre de rééducation professionnelle
Sends a claimant to the board's rehabilitation centre for services, or orders supplies, along with the reason for the referral.
- Completed by
- Physician or NP (referral source)
- Issued by
- WorkSafeNB
- Format
- Language
- English and French
-
SUCCEED Discharge Report
Résumé de dossier RÉUSSIR
Closes a worker's course in the SUCCEED program by recording when treatment took place, the worker's work status and the results.
- Completed by
- Psychologist, social worker or counselling therapist
- Issued by
- WorkSafeNB
- Format
- Fillable PDF
- Language
- English and French
-
WorkSafeNB Opioid Review Process
Processus d'examen de la thérapie par les opiacés – Travail sécuritaire NB
Works through opioid coverage requests, whether the drug falls beyond standard criteria or approval is ongoing, with the prescriber and pharmacist each completing their part.
- Completed by
- Prescribing physician and pharmacist
- Issued by
- WorkSafeNB
- Format
- Language
- English and French
-
WorkSafeNB Telephone Consultation and Case Conference Form
Formulaire de consultation par téléphone et de conférence de cas de Travail sécuritaire NB
Lets a physician record and bill a phone consultation or case conference that the board started or asked for.
- Completed by
- Physician (primary care or specialist)
- Issued by
- WorkSafeNB
- Format
- Language
- English and French
Insurance claims
- FORM-1063E
Attending Physician's Statement - Application for Benefits
Supports a long-term disability benefit or waiver of premium under provincial employee plans with the physician's account of the patient's condition.
- Completed by
- Attending physician
- Issued by
- Government of New Brunswick employee benefits (Medavie Blue Cross)
- Format
- Fillable PDF
- Language
- English
Government benefits and tax credits
-
Attending Physician's Statement – Application for Disability Pension
Backs an application for a disability pension from the pension plan for teachers or the provincial court judges' pension act.
- Completed by
- Attending physician
- Issued by
- Vestcor (NB Teachers' Pension Plan; Provincial Court Judges)
- Format
- Fillable PDF
- Language
- English
-
Disability Category - Medical Report
Backs an adult's request to be certified disabled by the advisory board, which unlocks extended benefits.
- Completed by
- Physician or specialist ('appropriate practitioner' per policy)
- Issued by
- NB Social Development
- Language
- English and French
-
Disability Verification Form
Formulaire de vérification de l'invalidité
Confirms a student's permanent or prolonged disability so they can access disability funding under New Brunswick's integrated student aid; the right assessor depends on the disability type.
- Completed by
- Qualified medical assessor by disability type: physician or NP (mobility/agility, cognitive); ophthalmologist or optometrist (visual); certified audiologist (hearing); speech-language pathologist (speech); psychologist, physician or NP (ADD/ADHD, autism); clinical psychologist, psychiatrist, physician or NP (psychiatric/psychological)
- Issued by
- NB Post-Secondary Education, Training and Labour - Student Financial Services
- Format
- Fillable PDF
- Language
- English and French
-
Examination Report - Blind Category
Records the eye exam that certifies an assistance claimant as legally blind, qualifying them for extended benefits.
- Completed by
- Ophthalmologist or optometrist (policy: 'confirmed to be legally blind by an ophthalmologist or optometrist')
- Issued by
- NB Social Development
- Language
- English and French
-
Examination Report - Deaf Category
Records the hearing exam that certifies an assistance claimant as deaf, qualifying them for extended benefits.
- Completed by
- 'Appropriate practitioner' (the policy doesn't name the profession)
- Issued by
- NB Social Development
- Language
- English and French
-
SD Medical Report
States that an assistance applicant or client cannot work for six months or more, or is seven or more months pregnant, which sets their rate and income exemptions.
- Completed by
- Physician
- Issued by
- NB Social Development
- Language
- English and French
Drug coverage
-
Correctional Services Special Authorization Request forms (3 forms)
Bundles three authorization requests for people held in provincial correctional services: a general one, one for smoking cessation therapy and one for Paxlovid.
- Completed by
- Prescriber (requestor) serving correctional clients
- Issued by
- NB Drug Plans (Department of Health)
- Format
- Fillable PDF
- Language
- English
- FORM-968E
Filgrastim / Pegfilgrastim Special Authorization Request
Filgrastim / Pegfilgrastim - Demande d'autorisation spéciale
Requests coverage of filgrastim or pegfilgrastim for chemotherapy support, non-malignant neutropenia or stem cell transplant support.
- Completed by
- Prescriber (requestor)
- Issued by
- NB Drug Plans (Department of Health)
- Format
- Fillable PDF
- Language
- English and French
- FORM-791E
New Brunswick Drug Plans Special Authorization Request
Régimes de médicaments du Nouveau-Brunswick - Demande d'autorisation spéciale
Asks New Brunswick's prescription drug programs to cover a drug that needs special authorization and has no form of its own.
- Completed by
- Prescriber (requestor)
- Issued by
- NB Drug Plans (Department of Health)
- Format
- Fillable PDF
- Language
- English and French
- FORM-1238E
Nirmatrelvir/Ritonavir (Paxlovid) Special Authorization Request
Nirmatrelvir/Ritonavir (Paxlovid) - Demande d'autorisation spéciale
Confirms a patient meets the clinical criteria for New Brunswick coverage of nirmatrelvir with ritonavir.
- Completed by
- Prescriber (requestor)
- Issued by
- NB Drug Plans (Department of Health)
- Format
- Fillable PDF
- Language
- English and French
- FORM-917E
Smoking Cessation Therapy Special Authorization Request
Thérapie d'abandon du tabac - Demande d'autorisation spéciale
Requests extra coverage for smoking cessation therapy under New Brunswick's special authorization process.
- Completed by
- Prescriber (requestor)
- Issued by
- NB Drug Plans (Department of Health)
- Format
- Fillable PDF
- Language
- English and French
Driving and licensing
- CSS-FOL-78-9282E
Medical Fitness Report
Rapport d'état de santé
Reports on any medical conditions that could affect a driver's safety behind the wheel, needed when a New Brunswick licence application or renewal calls for a medical.
- Completed by
- Licensed medical practitioner or nurse practitioner
- Issued by
- Service New Brunswick (Motor Vehicle Branch)
- Format
- Fillable PDF
- Language
- English and French
Mental health and medico-legal
- Form 1
Form 1 - Examination Certificate
Formule 1 - Certificat d'examen
Certifies that a person may have a serious mental illness needing hospitalization, allowing custody, transfer to a psychiatric facility and detention of up to 72 hours for assessment.
- Completed by
- Physician practising in New Brunswick who personally examined the person
- Issued by
- New Brunswick Department of Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- Form 12
Form 12 - First Certificate of Detention
Formule 12 - Premier certificat de détention
Keeps an involuntary patient detained for up to a month once the period set by the tribunal order ends.
- Completed by
- Attending psychiatrist (on personal examination)
- Issued by
- New Brunswick Department of Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- Form 13
Form 13 - Second Certificate of Detention
Formule 13 - Deuxième certificat de détention
Keeps an involuntary patient detained for as long as two further months once the first certificate lapses, signed jointly by two psychiatrists who each examined the patient.
- Completed by
- Attending psychiatrist and a second psychiatrist, both on personal examination
- Issued by
- New Brunswick Department of Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- Form 2.1
Form 2.1 - Application for Admission of a Person as an Involuntary Patient
Formule 2.1 - Demande d'admission d'une personne à titre de malade en placement non volontaire
Asks the tribunal for an order making a person an involuntary patient, whether they arrived on an examination certificate, a judge's order or voluntarily, with the examination report.
- Completed by
- Attending psychiatrist practising in New Brunswick
- Issued by
- New Brunswick Department of Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- Form 34.I
Form 34.I - Supervised Community Care Plan-Application
Formule 34.I - Demande de plan de soins communautaires supervisés
Applies to the review board for supervised care in the community, laying out eligibility, the planning meeting, who does what, appointments, medications and housing.
- Completed by
- Applying psychiatrist (attending psychiatrist if hospitalized, community psychiatrist if not); client signs an acknowledgement; person reviewing the plan with the client signs
- Issued by
- New Brunswick Department of Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- Form 34.VII
Form 34.VII - Supervised Community Care - Renewal Form
Formule 34.VII - Soins communautaires supervisés - Formule de renouvellement
Renews a community supervision plan for another year by confirming the criteria still hold and that the plan has been working.
- Completed by
- Applying psychiatrist (individual also signs)
- Issued by
- New Brunswick Department of Health (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
Parking, transit and travel
- 24-01283
Application for Disabled Parking Permit
Demande de permis de stationnement pour personne handicapée
Used to request a disabled parking permit and placard in New Brunswick, which is issued as either a temporary permit lasting up to five years or a permanent one.
- Completed by
- Physician, occupational therapist, physiotherapist, NP or chiropractor
- Issued by
- Service New Brunswick
- Format
- Fillable PDF
- Language
- Bilingual
- MOB-FRM-060E
Para Transit Registration
A confidential questionnaire about the patient's health problem, which lets Fredericton Para Transit staff decide on eligibility and what accommodations are needed.
- Completed by
- Qualified health care provider familiar with the applicant's condition, e.g., physician, NP, RN, OT, physiotherapist, recreational therapist, psychologist or psychiatrist
- Issued by
- City of Fredericton (Fredericton Transit)
- Format
- Language
- English
Health programs
-
Confirmation of Medical Eligibility for Glucose Sensor Coverage
Confirmation de l'admissibilité médicale à la couverture des capteurs de glucose
Confirms a client meets the medical criteria for continuous glucose monitoring sensor coverage, completed by the physician or diabetes educator managing their care.
- Completed by
- Physician or Certified Diabetes Educator (CDE) who manages the client's diabetes
- Issued by
- NB Insulin Pump Program (Department of Health / Vitalité Health Network)
- Format
- Fillable PDF
- Language
- English and French
-
Confirmation of Medical Eligibility for Pump and Supplies Coverage
Confirmation d'admissibilité médicale à la couverture de pompes et fournitures
Confirms a client meets the medical criteria for insulin pump and pump supplies coverage, approved by an endocrinologist, internist or paediatrician.
- Completed by
- Diabetes specialist for pump approval (endocrinologist, internal medicine physician or pediatrician)
- Issued by
- NB Insulin Pump Program (Department of Health / Vitalité Health Network)
- Format
- Fillable PDF
- Language
- English and French
- 35-5161
Request for Prior Approval - Medicare
Demande d'approbation préalable - Assurance-maladie
Asks Medicare to decide in advance whether a proposed service that may be cosmetic is insured, citing the service code, units, diagnosis and functional impairment.
- Completed by
- Physician (performing practitioner; referring practitioner identified)
- Issued by
- NB Department of Health - Medicare
- Format
- Language
- Bilingual
Other forms
-
Anaesthesia Billing Form for WorkSafeNB Claimants
Formulaire de facturation pour l'anesthésie à l'intention des travailleurs blessés de Travail sécuritaire NB
Bills the board for anaesthesia given to an injured worker, with modifiers for after-hours care and BMI.
- Completed by
- Anaesthesiologist
- Issued by
- WorkSafeNB
- Format
- Language
- English and French
-
Doctor's Account for Consultations and Procedures
Compte du médecin pour consultations et actes médicaux
Invoices the board for consultations and procedures a physician or NP performed on a worker's claim.
- Completed by
- Physician or NP
- Issued by
- WorkSafeNB
- Format
- Language
- English and French
-
Surgery Billing Form for WorkSafeNB Claimants
Formulaire de facturation pour la chirurgie à l'intention des travailleurs blessés de Travail sécuritaire NB
Bills the board for surgery on a claimant, covering the primary surgeon, general practitioner or specialist assistants and collaborative surgery.
- Completed by
- Surgeon or surgical assistant
- Issued by
- WorkSafeNB
- Format
- Language
- English and French
Nova Scotia
Workers' compensation
-
WCB Nova Scotia's report on whether a worker's hand and wrist symptoms, often possible carpal tunnel syndrome, are related to work. The family doctor completes, signs and dates it.
- Completed by
- Family physician
- Issued by
- Workers' Compensation Board of Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
WCB Nova Scotia's report on a worker's traumatic eye injury and any resulting impairment. An eye specialist (ophthalmologist) completes, signs and dates it.
- Completed by
- Ophthalmologist
- Issued by
- Workers' Compensation Board of Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
The request a prescriber sends to Medavie Blue Cross when a worker with a WCB Nova Scotia claim needs a non-opioid drug that isn't covered on their formulary. The prescriber completes and signs it.
- Completed by
- Prescriber
- Issued by
- Workers' Compensation Board of Nova Scotia, administered by Medavie Blue Cross
- Format
- Fillable PDF
- Language
- English
-
The request a prescriber sends to Medavie Blue Cross when a worker with a WCB Nova Scotia claim needs an opioid that isn't automatically covered. The prescriber completes and signs it.
- Completed by
- Prescriber
- Issued by
- Workers' Compensation Board of Nova Scotia, administered by Medavie Blue Cross
- Format
- Fillable PDF
- Language
- English
- Form E
Physical Abilities Report
WCB Nova Scotia's form for out-of-province treatment providers to record a worker's tested physical abilities against their job demands over the course of treatment. The treating provider completes it.
- Completed by
- Treating health care provider at an approved out-of-province clinic
- Issued by
- Workers' Compensation Board of Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
WCB Nova Scotia's report from the physician or nurse practitioner treating a worker's injury, sent at the first visit and updated at later visits. The practitioner completes and certifies it.
- Completed by
- Physician or nurse practitioner
- Issued by
- Workers' Compensation Board of Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Audiometric Report
Provides current hearing test results and findings for a worker's hearing loss claim.
- Completed by
- Audiologist
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
CTS - Physician Hand/Wrist Report
Assesses carpal tunnel syndrome for a hand or wrist claim, with history, medications, height and weight, lab results and nerve testing.
- Completed by
- Physician
- Issued by
- WCB Nova Scotia
- Format
- Language
- English
-
Dental Claim Form
Bills the board for dental work on a claim, listing procedure codes, teeth treated, fees and lab charges.
- Completed by
- Dentist
- Issued by
- WCB Nova Scotia
- Format
- Language
- English
-
EXTENSION REQUEST FORM for Medical Cannabis
Asks the board to keep covering a worker's medical cannabis beyond the initial approval, on a five page form.
- Completed by
- Authorizing health care practitioner (physician or NP)
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Eye Injury Report
Helps the board rate impairment after a traumatic eye injury at work, completed by an eye specialist.
- Completed by
- Ophthalmologist (eye specialist)
- Issued by
- WCB Nova Scotia
- Format
- Language
- English
- Form B
Form B: Initial Assessment (For out of province providers)
Reports a first assessment of a worker's physical or psychological injury from a provider located outside the province.
- Completed by
- Treating health care provider (e.g., physiotherapist, chiropractor)
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Hearing Loss Exception to Benefits Form
Seeks board sign-off on hearing devices or services that go beyond the standard hearing loss benefits, with the worker completing the cost-sharing section.
- Completed by
- Audiologist or hearing instrument specialist; the worker completes the cost-sharing section
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
INITIAL REQUEST FORM for Medical Cannabis
Asks the board to cover medical cannabis for a worker for the first time, on a seven page form.
- Completed by
- Authorizing health care practitioner (physician or NP)
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
- Form A
Intake Report – Form A
Opens a worker's tiered services care by capturing details on the worker, their family doctor, the employer and the job.
- Completed by
- Treating health care provider (tiered services clinic)
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Mandatory Generic Exemption Request
Asks for an exception when a worker needs a brand-name drug despite the board's policy of covering generics.
- Completed by
- Prescriber
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
NON-OPIOID Special Authorization Request Form
Requests coverage for a non-opioid drug that the board does not pay for automatically.
- Completed by
- Prescriber
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Pain Medication (OPIOID) Special Authorization Request Form
Requests coverage for opioid pain relief on a worker's claim, which needs special authorization from the board.
- Completed by
- Prescriber
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Physician – Assistive Devices Request Form
Prescribes or requests an assistive device for an injured worker, with the case worker filling in the request and worker sections.
- Completed by
- Physician (the case worker completes the request and worker sections)
- Issued by
- WCB Nova Scotia
- Format
- Language
- English
-
Primary and Emergency Care Report
Reports a physical or psychological injury from work at the first visit, covering the incident, diagnosis, notes, treatment and obstacles to returning to work, then gets updated later.
- Completed by
- Physician or NP
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
- Form C
Progress Report – Form C (For out of province providers)
Updates the board on a worker's treatment from a provider located outside the province.
- Completed by
- Treating health care provider
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Psychology Assessment Form: REPORT
Reports a psychologist's first assessment of an injured worker with a psychological condition, for providers based outside the province.
- Completed by
- Psychologist
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Psychology Progress Form: REPORT
Tracks how a worker is responding to psychological treatment over time, for providers based outside the province.
- Completed by
- Psychologist
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Referral Form for Centralized Surgical Services Program
Refers an injured worker to the board's surgical program for a non-urgent surgical assessment, with the diagnosis and how the injury happened.
- Completed by
- Physician
- Issued by
- WCB Nova Scotia
- Format
- Language
- English
-
Service Provider – Assistive Devices Request Form
Requests an assistive device for a worker, with type, cost and warranty, plus a section for orthotics and footwear.
- Completed by
- Health care provider (e.g., physiotherapist, chiropractor, orthotist); the case worker completes Sections A-B
- Issued by
- WCB Nova Scotia
- Format
- Language
- English
-
Substance Abuse Assessment Form
Screens a worker's risk of substance use, and must be on file before the board will consider later opioid authorization requests.
- Completed by
- Prescriber
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
-
Tiered Services - Additional Information Form
Accompanies reports from tiered services providers with extra detail the main report does not cover.
- Completed by
- Treating health care provider
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
Insurance claims
- NS-1A
NS-1A Claim for Disability Benefits
Claims Section B disability income benefits following a Nova Scotia auto accident, and a medical doctor certifies how long the claimant was totally disabled.
- Completed by
- Claimant or authorized representative (Parts 1-2); medical doctor (Parts 3-4)
- Issued by
- Nova Scotia Superintendent of Insurance (Finance and Treasury Board)
- Format
- Language
- English
- NS-2
NS-2 Treatment Plan
Lays out the plan of treatment for a whiplash, sprain or strain injury following a Nova Scotia auto accident, and notes whether the claimant chose treatment within the protocols.
- Completed by
- Primary health care practitioner (medical doctor, chiropractor or physical therapist) who intends to provide most of the treatment or coordinate care; claimant or representative completes Parts 1, 2 and 7
- Issued by
- Nova Scotia Superintendent of Insurance (Finance and Treasury Board)
- Format
- Language
- English
- NS-2A
NS-2A Confirmation of Services Provided
Itemizes treatments, supplies and services given to an auto accident claimant, mainly so adjunct therapy can be reimbursed, with signed confirmations.
- Completed by
- Primary health care practitioner and adjunct therapy provider (acupuncturist or massage therapist); claimant or representative signs the confirmation
- Issued by
- Nova Scotia Superintendent of Insurance (Finance and Treasury Board)
- Format
- Language
- English
- NS-3
NS-3 Progress Report
Tells the auto insurer the claimant's diagnosis, what the examination found and how close they are to their functional goals while receiving care under the Diagnostic and Treatment Protocols.
- Completed by
- Primary health care practitioner (medical doctor, chiropractor or physiotherapist)
- Issued by
- Nova Scotia Superintendent of Insurance (Finance and Treasury Board)
- Format
- Language
- English
- NS-4
NS-4 Concluding Report
Wraps up care under the Diagnostic and Treatment Protocols by giving the assessment status, a treatment summary, why the claimant was discharged and their status then, as the insurer requires.
- Completed by
- Primary health care practitioner who completed the majority of the patient's treatments (N.S. Reg. 20/2013 s. 36(1))
- Issued by
- Nova Scotia Superintendent of Insurance (Finance and Treasury Board)
- Format
- Language
- English
- NS-5
NS-5 Referral Form
Sends a claimant hurt in an auto accident to another practitioner or an injury management consultant, giving the reason, the injury and the treatment given so far.
- Completed by
- Referring primary health care practitioner (Section 2); claimant, representative or practitioner completes Section 1 claimant details
- Issued by
- Nova Scotia Superintendent of Insurance (Finance and Treasury Board)
- Format
- Language
- English
Government benefits and tax credits
-
Medical Assessment
Documents a disability or chronic illness in an applicant, recipient or dependent, to decide basic needs, special needs, a monthly disability supplement and employment services.
- Completed by
- Qualified medical practitioner or nurse practitioner (manual also refers to 'other medical professionals')
- Issued by
- NS Opportunities and Social Development (ESIA)
- Language
- English
-
Physician Report - Medical Assessment
Required with every application to the Disability Support Program, and care coordinators can also request updates or decisions about a participant's capacity to consent.
- Completed by
- Attending physician or nurse practitioner familiar with the applicant and their medical history
- Issued by
- NS Opportunities and Social Development (Disability Support Program)
- Language
- English
-
Request for Essential Medical Treatment
Asks the program to pay for a prescribed item or service it normally excludes, like massage, acupuncture or chiropractic, with diagnosis, alternatives tried and efficacy.
- Completed by
- Health practitioner licensed in NS as a physician, dentist or nurse practitioner
- Issued by
- NS Opportunities and Social Development (ESIA)
- Language
- English
-
Verification of Disability Form for Students with Disabilities
Confirms a student's lasting or prolonged disability so they can reach federal and provincial disability grants through Nova Scotia student assistance, with the assessor depending on the condition.
- Completed by
- Audiologist (hearing); ophthalmologist or optometrist (visual); physician, NP, psychologist, psychiatrist or occupational therapist (neurodevelopmental, physical, neurological, psychiatric, chronic)
- Issued by
- NS Advanced Education - Post-Secondary Accessibility Services (PSAS) / Nova Scotia Student Assistance
- Format
- Fillable PDF
- Language
- English
Drug coverage
-
Palliative Care Drug Program Application Form
Enrols a patient with end-stage terminal illness who lives at home in Nova Scotia's palliative care drug program.
- Completed by
- Palliative care physician or nurse (authorizer)
- Issued by
- NS Pharmacare Programs (Health and Wellness)
- Format
- Language
- English
-
Pharmacare Exception Status Drug (ESD) request via Ocean (ESD Pilot)
Submits an exception status drug request online through an Ocean account instead of filling in the PDF forms, as part of a pilot.
- Completed by
- Prescriber with an Ocean account
- Issued by
- NS Pharmacare Programs (Health and Wellness)
- Format
- Online portal or EMR
- Language
- English
-
Pharmacare Programs specialized exception status drug request forms (58 drug/condition-specific forms)
Gathers Nova Scotia's drug-specific and condition-specific request forms for exception status drugs, spanning arthritis, diabetes, asthma, migraine, hepatitis C and inflammatory bowel disease.
- Completed by
- Prescriber
- Issued by
- NS Pharmacare Programs (Health and Wellness)
- Format
- Fillable PDF
- Language
- English
-
Request for Coverage of Exception Status Drug
Asks Nova Scotia Pharmacare to cover an exception status drug when none of the more specialized request forms applies.
- Completed by
- Prescriber
- Issued by
- NS Pharmacare Programs (Health and Wellness)
- Format
- Fillable PDF
- Language
- English
-
Request for Insured Coverage of Agents for Attention Deficit Hyperactivity Disorder
Requests insured coverage of ADHD medications such as long-acting agents under Nova Scotia's exception status drug rules.
- Completed by
- Prescriber
- Issued by
- NS Pharmacare Programs (Health and Wellness)
- Format
- Fillable PDF
- Language
- English
Driving and licensing
-
Driver's Medical Examination Report
Documents a driver's fitness for licence classes 1 to 4, which you meet at first application, at renewal, yearly after 64, or when the Registry asks.
- Completed by
- Physician or NP (family physician, walk-in/locum, specialist or NP)
- Issued by
- Nova Scotia RMV
- Format
- Language
- English
- CER12Form22Z
Eye Examination Report
Records acuity, colour vision, double vision and visual fields so the registry can judge whether a driver's eyesight meets the standard for their licence class.
- Completed by
- Optometrist or ophthalmologist
- Issued by
- Nova Scotia RMV
- Format
- Language
- English
Mental health and medico-legal
- Form 10
Form 10 - Renewal of Community Treatment Order
Extends an existing community treatment order for a further 180 days, signed with a witness.
- Completed by
- Attending psychiatrist (signed in the presence of one subscribing witness)
- Issued by
- Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)
- Format
- Language
- English
- Form 2
Form 2 - Certificate for Involuntary Psychiatric Assessment - Part 1
Certifies, following an examination, that someone meets the legal criteria; two physicians' certificates, or one plus Form 3, allow a 72-hour hold, custody and a psychiatric assessment.
- Completed by
- Physician who examined the person (two separate physicians, unless Form 3 is used)
- Issued by
- Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)
- Format
- Language
- English
- Form 4
Form 4 - Declaration of Involuntary Admission
Admits a patient as an involuntary inpatient once the psychiatric assessment is done, for a period of up to 30 days.
- Completed by
- Psychiatrist on the staff of the facility who conducted the involuntary psychiatric assessment
- Issued by
- Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)
- Format
- Language
- English
- Form 5
Form 5 - Declaration of Renewal of Involuntary Admission
Renews an involuntary inpatient's status for 30, 60 or 90 days, declared by the attending psychiatrist.
- Completed by
- Attending psychiatrist on the staff of the psychiatric facility
- Issued by
- Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)
- Format
- Language
- English
- Form 9
Form 9 - Community Treatment Order
Orders treatment in the community instead of hospital, with a treatment plan, for a term of up to 180 days.
- Completed by
- Attending psychiatrist (signed in the presence of one subscribing witness)
- Issued by
- Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)
- Format
- Language
- English
Parking, transit and travel
- APP11
Application for Accessible Parking Identification Permits and Plates
For a patient with a mobility disability, requests a permanent permit lasting five years, a temporary permit of up to six months, or special accessible licence plates.
- Completed by
- Physician ('qualified Medical Practitioner')
- Issued by
- Nova Scotia RMV
- Format
- Language
- English
-
Application for Accessible Parking Motorcycle Plate
Applies for an accessible parking plate for a motorcycle on behalf of a patient with a permanent mobility disability.
- Completed by
- Physician or licensed NP
- Issued by
- Nova Scotia RMV
- Format
- Language
- English
Health programs
-
Gender Affirming Surgery Application
Asks for pre-approval of insured surgery for gender affirmation, including surgery referred outside the province, and the patient completes their own personal sections.
- Completed by
- Nova Scotia physician, nurse practitioner or specialist (patient completes personal sections)
- Issued by
- NS Health and Wellness - MSI (Nova Scotia Health Insurance Program)
- Format
- Fillable PDF
- Language
- English
-
Medical Status Report For Admission to a Long-Term Care Facility
Gives the current diagnoses and medical condition of a stable patient who wants to be admitted to a facility for long-term care.
- Completed by
- Qualified medical practitioner or nurse practitioner
- Issued by
- NS Seniors and Long-Term Care (Continuing Care)
- Format
- Fillable PDF
- Language
- English
Prince Edward Island
Lab and imaging requisitions
- 101038.0007
Laboratory Blood Test Request Form
Orders blood work at the Provincial Clinical Laboratory or hospital collection sites, across chemistry, cardiac, lipid, endocrine, tumour marker and drug-level tests.
- Completed by
- Ordering physician or nurse practitioner; collector completes specimen collection fields
- Issued by
- Health PEI (Provincial Laboratory Services)
- Format
- Fillable PDF
- Language
- English
- Q74-05
Request for Diagnostic Consultation
Orders diagnostic imaging in PEI, from general radiography and CT to nuclear medicine, bone density, mammography, ultrasound and MRI.
- Completed by
- Physician or nurse practitioner
- Issued by
- Health PEI (Diagnostic Imaging)
- Format
- Language
- English
Workers' compensation
-
Chiropractor Report
Used for a chiropractor's first assessment, progress report, discharge or amended billing on a PEI work injury, with the diagnosis, treatment, findings and recommended status for work.
- Completed by
- Chiropractor
- Issued by
- WCB PEI
- Format
- Language
- English
- CL-66
Counselling Report
Reports on a worker's counselling, with the dates of in-person and virtual sessions, symptoms, modalities used, the worker's response and engagement, and psychosocial measures.
- Completed by
- Counsellor or psychologist (mental health provider)
- Issued by
- WCB PEI
- Format
- Fillable PDF
- Language
- English
- CL-54
Fit For Work Assessment
Weighs a worker's functional tolerances against the reported job demands, using history, a musculoskeletal exam and functional abilities.
- Completed by
- Clinic-based assessor (regulated health professional named on the form)
- Issued by
- WCB PEI
- Format
- Fillable PDF
- Language
- English
- CL-53
Functional Scan
Compares a worker's maximum ability levels against their pre-injury job demands, repeated across up to four serial scans.
- Completed by
- Treating clinic clinician (named on the form)
- Issued by
- WCB PEI
- Format
- Fillable PDF
- Language
- English
-
Physiotherapist Report
Used for a physiotherapist's first assessment, progress report, discharge or amended billing on a PEI work injury, with the diagnosis, treatment, findings and recommended status for work.
- Completed by
- Physiotherapist
- Issued by
- WCB PEI
- Format
- Language
- English
Government benefits and tax credits
-
Permanent or Persistent or Prolonged Disability Medical Assessment Form
Confirms a student's disability is permanent, persistent or prolonged, to qualify for funding through the Canada Student Grant and for disability-related goods and services.
- Completed by
- Qualified medical assessor matched to the disability (student completes Sections A and B)
- Issued by
- PEI Student Financial Services
- Format
- Language
- English
-
Social Programs Health Report
Covers medical conditions, employability and how disability affects daily living, and establishes eligibility for AccessAbility Supports and probably other social programs.
- Completed by
- Health care practitioner (medical practitioner)
- Issued by
- PEI Social Development (form header: Department of Social Development & Housing; now Social Development and Seniors)
- Format
- Language
- English
Drug coverage
-
Special Authorization Request - Crohn's Disease
Asks the High Cost Drug Program to cover a biologic or targeted therapy for Crohn's disease that is moderate to severe.
- Completed by
- Prescriber
- Issued by
- PEI Pharmacare (Health PEI)
- Format
- Language
- English
-
Special Authorization Request - DPP-4 / SGLT2 Inhibitors
Requests Diabetes Drug Program coverage of canagliflozin, empagliflozin, linagliptin or saxagliptin for a patient with type 2 diabetes.
- Completed by
- Physician, nurse practitioner or pharmacist
- Issued by
- PEI Pharmacare (Health PEI)
- Format
- Language
- English
-
Special Authorization Request - Psoriatic Arthritis
Requests High Cost Drug Program coverage of a biologic or targeted therapy for psoriatic arthritis, noting whether a rheumatologist is prescribing.
- Completed by
- Prescriber (the form asks whether a rheumatologist is prescribing)
- Issued by
- PEI Pharmacare (Health PEI)
- Format
- Language
- English
-
Special Authorization Request - Semaglutide
Requests Diabetes Drug Program coverage of semaglutide for type 2 diabetes once metformin and a sulfonylurea have been tried.
- Completed by
- Physician, nurse practitioner or pharmacist
- Issued by
- PEI Pharmacare (Health PEI)
- Format
- Language
- English
-
Standard Special Authorization Request
Asks PEI Pharmacare to pay for a formulary drug that requires special authorization when no dedicated form exists for it.
- Completed by
- Physician, nurse practitioner or pharmacist
- Issued by
- PEI Pharmacare (Health PEI)
- Format
- Language
- English
Driving and licensing
- DPC-2071
Driver's Medical Certificate
Records a driver's medical examination when the Registrar of Motor Vehicles requires one under the Highway Traffic Act before granting or keeping a licence.
- Completed by
- Physician (driver completes Part 1; optometrist or ophthalmologist may complete the vision section)
- Issued by
- PEI Highway Safety Division (Transportation and Infrastructure)
- Format
- Language
- English
Mental health and medico-legal
- Form 1
Form 1 - Order for Involuntary Psychiatric Assessment
Refers a person you have personally seen for an involuntary psychiatric assessment, and can be signed by physicians and nurse practitioners alike.
- Completed by
- Medical practitioner or nurse practitioner who personally examined the person
- Issued by
- PEI Department of Health and Wellness (Mental Health Act forms)
- Format
- Language
- English
- Form 4
Form 4 - Certificate of Renewal of Involuntary Admission
Continues a patient's involuntary stay for a month, three months or a year depending on the renewal, after the psychiatrist has reassessed them within 72 hours.
- Completed by
- Attending psychiatrist who personally assessed the patient within the previous 72 hours
- Issued by
- PEI Department of Health and Wellness (Mental Health Act forms)
- Format
- Language
- English
- Form 9
Form 9 - Renewal of Community Treatment Order
Extends a community treatment order that is already in place, completed by the psychiatrist responsible for it.
- Completed by
- Psychiatrist responsible for the community treatment order
- Issued by
- PEI Department of Health and Wellness (Mental Health Act forms)
- Format
- Language
- English
Newfoundland and Labrador
Lab and imaging requisitions
- R0001
Outpatient Specimen Collection Requisition
Orders most routine outpatient lab work in Newfoundland and Labrador, such as blood counts, chemistry, drug levels, urinalysis, prenatal panels and common infection tests.
- Completed by
- Ordering provider (physician, nurse practitioner or other clinician with ordering privileges); specimen collector completes collection fields
- Issued by
- NL Provincial Laboratory Formulary
- Format
- Fillable PDF
- Language
- English
Workers' compensation
- AR
Audiologist's Report (AR)
Documents an audiologist's assessment of a worker whose occupational hearing loss is the subject of a claim.
- Completed by
- Audiologist
- Issued by
- WorkplaceNL
- Format
- Language
- English
- 8/10C
Chiropractor's Report (Form 8/10C)
Serves as the single chiropractic report for a worker's first visit, progress, extension requests and discharge.
- Completed by
- Chiropractor
- Issued by
- WorkplaceNL
- Format
- Language
- English
-
Clinic-Based CBOR Reporting
Reports on a worker in clinic-based occupational rehabilitation at the start, during and at the end of the program.
- Completed by
- Attending licensed practitioner at a clinic-based occupational rehabilitation provider
- Issued by
- WorkplaceNL
- Format
- Language
- English
-
Commercial Divers Certificate of Medical Fitness
Certifies that a commercial diver is medically fit, as required by provincial occupational health and safety rules.
- Completed by
- Physician (diving medical examiner)
- Issued by
- WorkplaceNL
- Format
- Language
- English
-
Counselling Progress Report
Updates the board on counselling, including treatment methods, functioning, and how confident and ready the worker feels about going back to work or staying there.
- Completed by
- Counsellor with a WorkplaceNL vendor number (e.g., psychologist, social worker)
- Issued by
- WorkplaceNL
- Format
- Fillable PDF
- Language
- English
- DR
Dentist's Report (DR)
Reports a dentist's findings after examining a worker whose dental injury happened at work.
- Completed by
- Dentist
- Issued by
- WorkplaceNL
- Format
- Language
- English
- HA-01
HA-01 – Hearing Aid Purchase Order Request
Lets a hearing aid vendor request a purchase order for devices or services on a worker's claim.
- Completed by
- Hearing aid vendor (audiologist or hearing instrument practitioner)
- Issued by
- WorkplaceNL
- Format
- Language
- English
- HA-02
HA-02 – Hearing Aid Fitting Report
Documents a hearing aid fitting with the audiological profile, tympanometry results, the device fitted and an orientation checklist that the client signs.
- Completed by
- Hearing aid vendor (audiologist or hearing instrument practitioner)
- Issued by
- WorkplaceNL
- Format
- Language
- English
- HA-04
HA-04 Hearing Aid Repair Request
Asks the board to cover repairs to a worker's hearing aids and says why they are needed.
- Completed by
- Hearing aid vendor (audiologist or hearing instrument practitioner)
- Issued by
- WorkplaceNL
- Format
- Language
- English
- HA-05
HA-05 Hearing Aid Replacement
Requests a replacement for a worker's hearing aids, naming the current device, the reason and the proposed solution.
- Completed by
- Hearing aid vendor (audiologist or hearing instrument practitioner)
- Issued by
- WorkplaceNL
- Format
- Language
- English
- 53
Hand Injury (Form 53)
Reports a worker's hand injury and estimates how long it will take to reach maximum recovery.
- Completed by
- Treating health care provider
- Issued by
- WorkplaceNL
- Format
- Language
- English
-
Health Care Devices and Supplies Prescription
Prescribes a device or supply for an injured worker, giving the model, sizing and why it relates to the compensable injury.
- Completed by
- Prescribing health care provider (name and professional designation)
- Issued by
- WorkplaceNL
- Format
- Language
- English
-
Initial Counselling Report
Opens a worker's counselling file with the presenting problem, the counsellor's clinical assessment, a treatment plan and factors affecting return to work.
- Completed by
- Counsellor with a WorkplaceNL vendor number (e.g., psychologist, social worker)
- Issued by
- WorkplaceNL
- Format
- Fillable PDF
- Language
- English
- OR
OR Report Information
Serves as the cover sheet attached to occupational rehabilitation reports such as job site analyses, work site reports and functional assessments.
- Completed by
- Licensed practitioner delivering occupational rehabilitation services
- Issued by
- WorkplaceNL
- Format
- Fillable PDF
- Language
- English
- MD
Physician's Report (Form MD)
Reports a new work injury, a recurrence, or a significant change in a worker's status; the employer's copy reaches the employer via the worker.
- Completed by
- Physician
- Issued by
- WorkplaceNL
- Format
- Language
- English
- PR
Physiotherapist's Report (Form PR)
Serves as the one physiotherapy report for a worker's initial assessment, progress updates and discharge.
- Completed by
- Physiotherapist
- Issued by
- WorkplaceNL
- Format
- Language
- English
Government benefits and tax credits
-
Verification of Eligibility Form for Students with Disabilities
Confirms a student's lasting or prolonged disability so they can receive disability grants under the integrated Canada and Newfoundland and Labrador student aid program.
- Completed by
- Qualified medical assessor and/or educational assessor ('appropriate medical professional')
- Issued by
- NL Education - Student Financial Services (StudentAidNL)
- Format
- Fillable PDF
- Language
- English
Drug coverage
-
NLPDP drug-specific Special Authorization Request Forms (25 forms)
Collects 25 criteria-based request forms for specific drugs and classes, from inhalers and biologics to hepatitis C, HIV PrEP, antiplatelets and glucose test strips.
- Completed by
- Prescriber (physician or other healthcare professional; some have an optional pharmacist block)
- Issued by
- NL Health and Community Services - Pharmaceutical Services (NLPDP)
- Format
- Language
- English
-
Special Authorization Request Form
Requests special authorization drug coverage from Newfoundland and Labrador's provincial pharmacy program, with a separate block if another health professional is involved.
- Completed by
- Prescriber (separate block for another healthcare professional if different)
- Issued by
- NL Health and Community Services - Pharmaceutical Services (NLPDP)
- Format
- Language
- English
-
Special Authorization Request Form - Non-Insulin Anti-Diabetic Agents
Requests special authorization coverage for non-insulin diabetes medications under the provincial drug program, with an optional block for the pharmacist.
- Completed by
- Prescriber (physician or other healthcare professional); optional pharmacist block
- Issued by
- NL Health and Community Services - Pharmaceutical Services (NLPDP)
- Format
- Language
- English
Driving and licensing
-
Diabetic Questionnaire
Captures how a driver's diabetes is managed, including treatment type, awareness of low blood sugar, past episodes and glucose monitoring, when Motor Registration asks for it.
- Completed by
- Physician (signature block also allows NP)
- Issued by
- NL Motor Registration Division
- Format
- Fillable PDF
- Language
- English
-
Drivers Medical Examination Report
Covers a routine driver medical measured against the national medical standards for driver fitness, often requested for older or commercial drivers by letter.
- Completed by
- Physician or NP
- Issued by
- NL Motor Registration Division
- Format
- Fillable PDF
- Language
- English
-
Neurology Report Form
Reports on a driver's seizure disorder or other neurological condition so Motor Registration can decide whether the person is fit to drive.
- Completed by
- Physician or NP
- Issued by
- NL Motor Registration Division
- Format
- Fillable PDF
- Language
- English
-
Update Cognitive Function
Updates a driver's cognitive status after Motor Registration receives a report of possible memory problems, following the national standard's cognitive chapter.
- Completed by
- Physician or NP (form says 'health care provider')
- Issued by
- NL Motor Registration Division
- Format
- Fillable PDF
- Language
- English
-
Vision Referral Form
Reports how well a driver sees, including acuity, any lens correction needed and the horizontal field of vision, after Motor Registration refers them to an eye-care provider.
- Completed by
- Ophthalmologist or optometrist
- Issued by
- NL Motor Registration Division
- Format
- Fillable PDF
- Language
- English
Mental health and medico-legal
- MHCTA-01
Certificate of Involuntary Admission (MHCTA-01)
Admits a person involuntarily to a psychiatric unit through two certificates, which together permit detention for up to 30 days.
- Completed by
- First certificate: physician or nurse practitioner; second certificate: psychiatrist (or another physician if a psychiatrist is not readily available)
- Issued by
- NL Health and Community Services (Mental Health Care and Treatment Act forms)
- Format
- Fillable PDF
- Language
- English
- MHCTA-02
Certificate of Renewal (MHCTA-02)
Renews an involuntary patient's status, for 30 days, then 60, then 90 days with each later renewal.
- Completed by
- Attending physician
- Issued by
- NL Health and Community Services (Mental Health Care and Treatment Act forms)
- Format
- Fillable PDF
- Language
- English
- MHCTA-03
Community Treatment Order (MHCTA-03)
Sets up treatment in the community under a psychiatrist's order, with the patient's rights notice, transfer of responsibility and treatment plan, lasting six months unless renewed.
- Completed by
- Issuing psychiatrist (treatment team members named in the plan also sign)
- Issued by
- NL Health and Community Services (Mental Health Care and Treatment Act forms)
- Format
- Fillable PDF
- Language
- English
Parking, transit and travel
-
Accessible Parking Permit Application (Blue Zone Parking Application Form)
Handles a first application in Newfoundland and Labrador for an accessible parking permit, either temporary for six months or permanent for five years.
- Completed by
- Physician ('Medical Practitioner') or NP
- Issued by
- NL Motor Registration Division
- Format
- Fillable PDF
- Language
- English
-
GoBus Accessible Transit Application
Describes the disabilities and health problems that limit how a patient uses regular buses, so they can qualify for GoBus service in Mount Pearl and St John's.
- Completed by
- Health care professional such as a family physician, social worker, physiotherapist, mental health professional or OT
- Issued by
- Metrobus Transit (St. John's)
- Format
- Language
- English
Health programs
-
Long Term Care and Community Support Program Adult Needs Assessment
Records a client's needs to plan long-term care and community supports such as home support subsidy, completed by regional health authority staff rather than community physicians.
- Completed by
- Regional health authority assessor (care coordinator, nurse or social worker), not community physicians
- Issued by
- NL Health and Community Services
- Format
- Language
- English
-
Physician's Sample Template (Non-medical Escort Note)
Gives a patient's physician a letter template explaining why a non-medical escort must travel with them, which MTAP needs before covering the escort's trip.
- Completed by
- Physician (MTAP claim forms say escorts must be supported by documentation from a physician or nurse practitioner)
- Issued by
- NL Labrador Affairs - Medical Transportation Assistance Program (MTAP)
- Format
- Language
- English
Other forms
- 96
Invoice – Dentists (Form 96)
Joins a dentist's final report or report on a recurrence with the invoice that goes to the board for a worker's dental treatment.
- Completed by
- Dentist
- Issued by
- WorkplaceNL
- Format
- Language
- English
- 92
Invoice – Physicians (Form 92)
Bills the board for a physician's services on a worker's claim, serving as the physician's account.
- Completed by
- Physician
- Issued by
- WorkplaceNL
- Format
- Language
- English
Yukon
Workers' compensation
- F-0150
Chiropractor discharge report
Reports the end of a worker's chiropractic care under a Yukon claim.
- Completed by
- Chiropractor
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0149
Chiropractor progress report
Updates the board on a worker's chiropractic care during a Yukon claim.
- Completed by
- Chiropractor
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0093
Chiropractor's first report and assessment
Reports a chiropractor's first findings and assessment of a worker with a Yukon work injury.
- Completed by
- Chiropractor
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0103
Dentist's first report
Reports the first findings on a work-related dental injury for a Yukon claim.
- Completed by
- Dentist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0043
Doctor's first report
Starts a work injury claim in Yukon by giving the physician's first findings, the diagnosis, the plan for treatment and the follow-up.
- Completed by
- Physician
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
- F-0042
Doctor's progress report
Updates the board on how a worker is recovering from a Yukon work injury.
- Completed by
- Physician
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0044
Functional abilities form
Lists what a worker can and cannot do functionally, so the employer can make adjustments for a safe and early return to work.
- Completed by
- Health care provider (physician or other treating provider)
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
- F-0125
Massage Therapy Report
Records massage therapy treatment given to a worker under a Yukon claim.
- Completed by
- Massage therapist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0203
Physiotherapy Extension and Discharge Report
Requests more physiotherapy and reports discharge, including barriers to returning to work and recommendations.
- Completed by
- Physiotherapist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
- F-0199
Physiotherapy initial assessment report
Sets out the physiotherapist's first assessment, treatment plan and goals for a worker with a Yukon claim.
- Completed by
- Physiotherapist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
- F-0049
Prior approval request hearing claims
Requests approval in advance for hearing services or devices as part of a claim for hearing loss.
- Completed by
- Hearing service provider (audiologist / hearing instrument practitioner)
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0071
Psychological functional abilities form
Lists a worker's psychological and cognitive functional abilities and restrictions to plan a return to work.
- Completed by
- Psychologist or other mental health provider
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0077
Psychological initial assessment report
Gives the psychologist's first assessment of a worker with a Yukon work injury claim.
- Completed by
- Psychologist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0075
Psychological progress report
Updates the Yukon board on a worker's progress in psychological treatment after a work injury.
- Completed by
- Psychologist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
- F-0070
Service provider report hearing claims
Reports on the hearing services a provider delivered to a worker under a Yukon hearing loss claim.
- Completed by
- Hearing service provider (audiologist / hearing instrument practitioner)
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Language
- English
Mental health and medico-legal
- Form 11
Form 11 - Certificate of Renewal of Involuntary Admission
Formulaire 11 - Certificat de renouvellement d'admission non volontaire
Renews a patient's involuntary admission, with the attending physician plus another physician each completing a separate copy.
- Completed by
- Attending physician and one other physician, each completing a separate copy
- Issued by
- Yukon Health and Social Services (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- Form 12
Form 12 - Certificate of Change of Status
Formulaire 12 - Certificat de changement de statut
Cancels an earlier admission or renewal certificate, turning an involuntary patient into a voluntary one.
- Completed by
- Physician (the attending physician under s.17(2) of the Act)
- Issued by
- Yukon Health and Social Services (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- Form 4
Form 4 - Recommendation for Involuntary Psychiatric Assessment (Physician)
Formulaire 4 - Recommandation d'évaluation psychiatrique non volontaire (médecin)
Records a physician's mental health examination, which concludes with either release or a recommendation that the person be assessed involuntarily at a named designated facility.
- Completed by
- Examining physician (Yukon posts a separate nurse recommendation form)
- Issued by
- Yukon Health and Social Services (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- Form 7
Form 7 - Certificate of Involuntary Admission
Formulaire 7 - Certificat d'admission non volontaire
Admits someone to hospital against their will, with each of two examining physicians completing their own copy within 24 hours of the patient's arrival.
- Completed by
- Two physicians, each completing a separate copy within 24 hours of the patient's arrival at hospital
- Issued by
- Yukon Health and Social Services (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
Parking, transit and travel
- 6994YHC
Preferred Parking Request – Mobility Challenge Verification
Demande de stationnement réservé pour une personne à mobilité réduite
Verifies a tenant's permanent mobility condition so they can get preferred parking when they have no Whitehorse accessible parking permit.
- Completed by
- Tenant (Section 1); physician or primary health care nurse practitioner (Section 2)
- Issued by
- Yukon Housing Corporation
- Format
- Fillable PDF
- Language
- English and French
- 7320YHC
Priority Verification Form
Confirms that an applicant for income-geared rental housing needs priority because of family violence, a medical problem lacking local treatment, or a mobility problem making stairs a serious hazard.
- Completed by
- Third-party verifier. Sections B (medical accommodation) and C (mobility challenge): physician or nurse practitioner, or a community nurse where no physician or NP practises regularly in the community. Section A (family violence): also police officers, medical or mental health professionals, social workers or case managers, victim services workers, transition home executive directors and other family-violence service providers. Applicant completes Part 1
- Issued by
- Yukon Housing Corporation
- Format
- Fillable PDF
- Language
- English
Health programs
-
Continuing care facility or community day program referral
Refers a person for a spot in a long-term care home in Yukon or in the community day program, and anyone can submit the referral.
- Completed by
- Healthcare provider, the applicant, or family/caregiver (referrals accepted from any source)
- Issued by
- Yukon Health and Social Services - Continuing Care
- Format
- Language
- English
-
Hospice referral form
Refers a patient for hospice admission at a Yukon continuing care facility, completed by a member of their health-care team.
- Completed by
- Member of the patient's health-care team
- Issued by
- Yukon Health and Social Services - Continuing Care
- Format
- Language
- English
- 4840HSS
Medical Travel Subsidy
Claims the subsidy toward meals and lodging during approved medical travel, with each provider signing to confirm the service the patient received.
- Completed by
- Patient or guardian; the doctor, nurse or technician who provides each service signs to verify it
- Issued by
- Yukon Health and Social Services - Insured Health Services (Medical Travel Program)
- Format
- Fillable PDF
- Language
- English
-
Palliative Care Resource Team consult request form
Asks the territory's palliative care team to consult on a person with a life-limiting illness, and health professionals, family or volunteers can send it.
- Completed by
- Health care professionals (also family, friends or volunteers)
- Issued by
- Yukon Health and Social Services - Palliative Care Resource Team
- Format
- Language
- English
-
Yukon Healthy Living Program (YHLP) referral form
Refers a patient to Yukon's healthy living programs, which include the diabetes series, pulmonary rehabilitation and supervised exercise.
- Completed by
- Health care provider
- Issued by
- Yukon Health and Social Services - Chronic Conditions Support Program
- Format
- Language
- English
Other forms
-
Child care subsidy special needs application form
Supports a request for a larger subsidy toward child care costs when the child has special needs, based on the recommendation of a qualified professional.
- Completed by
- 'A qualified professional who can speak to the need(s) of your child, and has the appropriate training and skills to make the recommendation'
- Issued by
- Yukon Education - Early Learning and Child Care (Child Care Subsidy)
- Format
- Language
- English
Northwest Territories
Workers' compensation
- CS027
Dental Report and Estimate
Rapport et estimation – Soins dentaires
Reports a work-related dental injury to the commission and gives the dentist's estimate for treatment.
- Completed by
- Dentist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Language
- English and French
- CS003
First Medical Report
Premier rapport médical
Reports a work injury for the first time, and its back page has a Functional Abilities section for the attending provider to complete.
- Completed by
- Physician, nurse practitioner or other attending health care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS104
Functional Abilities – Behavioural, Cognitive and Emotional
Capacités fonctionnelles – comportementales, cognitives et émotionnelles
Lists the functional abilities and restrictions of a worker in the behavioural, cognitive and emotional areas, for planning their return to work.
- Completed by
- Treating health care provider (physician, psychologist or other)
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS057
Hand Arm Vibration (HAV) Syndrome Assessment Form
Évaluation du syndrome de vibration des avant-bras
Documents the clinical assessment when hand-arm vibration syndrome is suspected, which is an occupational disease.
- Completed by
- Physician or assessing health care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS009
Hand Injury Report
Rapport de blessure à la main
Documents a work-related hand injury for the commission, completed by the treating health care provider.
- Completed by
- Treating health care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS016
Massage Therapy Treatment
Massothérapie
Records a worker's massage therapy treatment dates and how they responded to therapy.
- Completed by
- Registered massage therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Language
- English and French
- CS004
Medical Progress Report
Rapport médical d'évolution
Keeps the commission informed of a worker's progress, and its Functional Abilities section is filled in whenever the worker's abilities change a great deal.
- Completed by
- Physician, nurse practitioner or other attending health care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS005
Medical Report Eye Injuries
Rapport médical – Blessures aux yeux
Documents a work-related eye injury for the commission, completed by the treating physician or eye-care provider.
- Completed by
- Treating physician or eye-care provider
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS007
Physiotherapy Request for Extension
Demande de prolongation – Physiothérapie et ergothérapie
Asks the commission to extend a worker's physiotherapy or occupational therapy beyond what was first approved.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Language
- English and French
- CS008
Physiotherapy/Occupational Therapy – Discharge Report
Physiothérapie / Ergothérapie Rapport de congé
Reports the discharge of a worker from physiotherapy or occupational therapy at the end of treatment.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Language
- English and French
- CS113
Physiotherapy/Occupational Therapy Functional Abilities Report – Form C
Physiothérapie / Ergothérapie Rapport sur les capacités fonctionnelles – Formulaire C
Reports a worker's functional abilities from physiotherapy or occupational therapy to help plan a return to work.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS111
Physiotherapy/Occupational Therapy Initial Assessment – Form A
Physiothérapie / Ergothérapie Première évaluation – Formulaire A
Gives the first physiotherapy or occupational therapy assessment, with a collaborative treatment plan and the worker's work capability.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS112
Physiotherapy/Occupational Therapy Progress Report – Form B
Physiothérapie / Ergothérapie Rapport d’étape – Formulaire B
Updates the commission on a worker's progress in physiotherapy or occupational therapy.
- Completed by
- Physiotherapist or occupational therapist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS103
Psychiatric/Psychological Initial Report
Rapport psychiatrique/psychologique initial
Gives the psychiatrist's or psychologist's first report on a worker whose work injury involves psychological symptoms.
- Completed by
- Psychiatrist or psychologist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
- CS102
Psychologist Progress Report
Rapport d’évolution du psychologue
Updates the commission on a worker's progress in psychological treatment after a work injury.
- Completed by
- Psychologist
- Issued by
- WSCC (Workers' Safety and Compensation Commission)
- Format
- Fillable PDF
- Language
- English and French
Government benefits and tax credits
- NWT9386
Form D - Disability Assessment
Formulaire D - Évaluation de l'incapacité
Medically confirms a disability for the income support program serving seniors and people with disabilities.
- Completed by
- Medical practitioner or nurse practitioner (Section 2); a registered nurse licensed in the NWT only if there is no access to an MD/NP within 3 months (Section 3)
- Issued by
- NWT Education, Culture and Employment - Income Security Programs
- Format
- Fillable PDF
- Language
- English and French
- NWT9008
Form G - Disability Assessment Form
Formulaire G - Évaluation de l'incapacité
Establishes eligibility for the NWT study grants for students with a permanent or persistent or prolonged disability.
- Completed by
- Qualified practitioner (form says 'i.e. medical doctor')
- Issued by
- NWT Education, Culture and Employment - Student Financial Assistance
- Format
- Fillable PDF
- Language
- Bilingual
Mental health and medico-legal
- NWT9053
Form 2 - Certificate of Involuntary Assessment
Formule 2 - Certificat d'évaluation non volontaire
Lets a health professional's examination lead to apprehension, transport to a designated facility and involuntary assessment and care lasting up to 72 hours.
- Completed by
- Health professional who examined the person (medical practitioner, nurse practitioner, psychologist or registered nurse allowed to practise in the NWT)
- Issued by
- NWT Health and Social Services (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- NWT9073
Form 22 - Assisted Community Treatment Certificate
Formule 22 - Certificat de traitement en milieu communautaire assisté
Lets a patient held involuntarily live outside the facility on a community treatment plan, for as long as six months, with the patient signing as well.
- Completed by
- Attending medical practitioner (patient and, if applicable, substitute decision maker also sign)
- Issued by
- NWT Health and Social Services (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- NWT9054
Form 3 - Certificate of Involuntary Admission
Formule 3 - Certificat d'admission involontaire
Admits someone to a designated facility on an involuntary basis for up to 30 days, signed by a practitioner other than the one who issued Form 2.
- Completed by
- Medical practitioner (not the one who issued Form 2)
- Issued by
- NWT Health and Social Services (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
- NWT9055
Form 4 - Renewal Certificate
Formule 4 - Certificat de renouvellement
Renews involuntary admission for 30 days the first time, 60 days the second time and 90 days after that.
- Completed by
- Attending medical practitioner
- Issued by
- NWT Health and Social Services (Mental Health Act forms)
- Format
- Fillable PDF
- Language
- English and French
Parking, transit and travel
-
Parking Permit Application
Requests an accessible parking permit in the Northwest Territories, whether new, renewed or replaced, and a clinician certifies that the mobility disability is temporary or permanent.
- Completed by
- Applicant or parent/guardian (Section 1); physician, occupational therapist, physical therapist, nurse practitioner or chiropractor (page 2)
- Issued by
- NWT Disabilities Council
- Format
- Language
- English
How this list is checked
Every form number, issuer, and link comes from the issuer's own website: the ministry, health authority, workers' compensation board, insurer, or laboratory that publishes the form. We last checked them in October 2026.
Issuers replace forms and move links without warning. If a link here is out of date, the issuer's site has the current version, and we'd like to hear about it at hello@medulla.ca.
Questions
Questions we hear a lot.
Where do these forms come from?
Each entry links to the issuer's official page and, where the issuer publishes one, the PDF itself. Issuers revise their forms without notice, so download the current version from the official page before you fill it.
Can I fill these forms in Medulla?
Yes, any form here that comes as a fillable PDF. Upload it once and anyone in your practice can fill it. Forms that live only in an online portal can't be filled this way. See how Medulla fills forms.
Which forms have a part for the patient?
Many disability, insurance, and benefits forms have a section the patient completes. In Medulla you can send that section to the patient over a secure link, and their answers come back on your form for you to finish.
Does Medulla submit forms for me?
No. You review the filled form, save it to the patient's chart or print it, and submit it the way the issuer asks.
Is patient information secure?
Yes. Medulla has a SOC 2 Type II report from an independent auditor, is HIPAA, PIPEDA, and PHIPA compliant, and is built and hosted in Canada, so patient data stays in the country and never gets pasted into consumer AI tools. Everything is encrypted in transit and at rest. See how we protect patient data.
More questions? Browse help.medulla.ca.