What the CLHIA medical statement is for
The Canadian life and health insurance industry created this standard form to collect the initial medical information needed to begin a disability claim. Many insurers use it in place of their own attending physician statement. The current version is dated June 2025. It’s often confused with the Service Canada medical certificate for EI sickness benefits, which is a separate federal form.
Who completes it
The patient completes Section 1: contact and employer details, policy and certificate numbers, dates last worked and expected return, current medications, height, weight and dominant hand. They write in the insurer’s name and sign the consent to release medical information. The doctor, a consulting specialist or another medical provider completes Section 2.
Usually the employer or insurer hands the patient a claim package, the patient fills in Section 1 and brings it in, and you complete Section 2 on the same paper or a separate copy. In Medulla, you can send Section 1 to the patient over a secure link before the visit. Their medication list and dates land on the PDF you complete Section 2 on, which saves you re-entering the medications under treatment.
How to fill in Section 2
Diagnosis and cause
Give the primary diagnosis, then secondary diagnoses and complications. Record a delivery date and type for childbirth. Answer whether the condition is due to an occupational illness or injury, a motor vehicle accident or another accident, and whether you’ve completed other disability forms recently, such as for CPP, QPP or a workers’ compensation board.
Treatment, response and hospitalization
List treatment not already noted by the patient, visit frequency, and the last and next visit dates. State whether the patient is following the recommended program and how they’ve responded. Record hospital stays and surgery dates, or attach admission, discharge and operative reports.
Investigations and clinical findings
For disabilities longer than four weeks, attach relevant test results, consultation reports and clinical notes. The insurer reads missing results as tests not performed. Describe the symptoms with history, severity and frequency, and whether they’ve improved, stayed the same or worsened.
Restrictions and limitations
Describe the cognitive and physical restrictions and limitations your findings support. Write them as functional limits, such as how long the patient can sit, lift or concentrate. Note any licence restricted because of the condition, whether the patient can manage their own affairs, and factors that may slow recovery.
Prognosis and return to work
Give the prognosis for improvement or recovery and the return-to-work goals you’ve discussed. Then sign and add your specialty, licence number and contact details.
Common reasons insurers come back for more
- A diagnosis with no restrictions or limitations.
- “Off work” with no expected return date or prognosis.
- Investigations mentioned but not attached, so the insurer treats them as not done.
- Only page one completed for a disability longer than four weeks.
- An unsigned patient consent, or the insurer’s name left blank.
Submitting and who pays
Give the completed form to the patient to send to their insurance carrier, or send it as the insurer’s instructions direct. CLHIA doesn’t process claims. The patient is responsible for the completion fee, so clinics bill the patient directly.