What the GH-0054 is for
The GH-0054 is Empire Life’s attending physician’s statement for a short term disability, or weekly indemnity, claim under a group benefits plan. It’s one of three parts of the claim, with the employee’s statement (GH-0053) and the employer’s statement (GH-0052). The version on Empire Life’s site is dated October 2017. Some insurers accept the industry’s CLHIA medical statement instead of their own, but Empire Life’s claim package names this one.
Who completes it
The employee completes the information and consent section: name, address, sex, height, weight, date of birth, employer, and the group policy, division and certificate numbers. They sign the authorization that lets you release medical information to Empire Life and accept responsibility for the fee. The attending physician completes the rest.
The employee normally gets the claim forms from their employer, fills in the top of this one and brings it to the visit. In Medulla, you can send the employee section to the patient over a secure link before the appointment. Their details and signed consent are on the PDF when you complete the statement, so Empire Life gets one complete form with the employee’s statement.
How to fill in the attending physician’s statement
Page one: diagnosis, dates and treatment
Give the primary and secondary diagnoses and complications, a delivery date for childbirth, and whether the condition is an occupational illness or injury or from an auto accident. Record the date of your first visit for this condition and the first date of work absence. Add any hospitalization or day surgery with dates, treatment, the prognosis for recovery and the expected return-to-work date.
Page two: history, symptoms and investigations
For absences that may exceed four weeks, say whether the patient has had the same or a similar condition before. Describe current symptoms with history, severity and frequency, and how often you see the patient. List surgery, tests or consultations still to come, and attach consultation reports and test results.
Restrictions and limitations
Describe the cognitive and physical restrictions and limitations your findings support, and any other conditions that affect function or the usual recovery time. Answer whether the patient is following the treatment program and whether you have concerns about their ability to manage their own affairs.
Physician details
Print your name, certified specialty, address, phone, fax and email, stamp the form, then sign and date it.
Common reasons it’s delayed
- Only page one completed for an absence longer than four weeks.
- No expected return-to-work date or prognosis.
- Restrictions left blank, or restating the diagnosis.
- Investigations mentioned but not attached.
- The employee’s consent unsigned.
Submitting and who pays
The form goes to Empire Life Group Solutions, Life and Disability Claims, 259 King Street East, Kingston, by mail, by fax to 1 855 430-9455 or by email to grouplifeanddisability@empire.ca. The patient is responsible for the completion fee, so clinics bill the patient directly.