What the 54-382A is for
iA uses the Extension of Disability form when it needs more information about a disability that has continued past the initial request. It asks whether the member is still unable to work and what has changed since the claim was opened. It covers short-term disability, long-term disability, and waiver of premium. iA is weighing whether the absence is lasting longer than usual for the diagnosis, so the form asks you directly for the factors behind your prognosis.
The 54-382A has no employer statement and no occupation section, unlike the initial request, the 54-381A, which opens the claim.
Who completes it
The member completes the Member’s Statement: identification, their current situation and symptoms, daily activities, expected return to work, and other sources of income, and signs the confirmation and authorization in Part 4. The member also completes the Member Identification section and signs the Member Authorization at the top of the physician’s statement. The attending physician completes the physical or psychological statement, Parts 1 to 5.
The member usually receives the form by mail from iA, fills in their statement at home, and brings the physician’s pages to an appointment, sometimes with the authorization at the top still unsigned. In Medulla, you send the Member’s Statement and identification section to the patient over a secure link before the visit. They fill it in on the form from any device, and their answers land on the same PDF you complete your statement on.
How to fill in the physician’s statement
Part 1, Diagnosis
On the physical statement, give the primary and secondary diagnoses, the objective tests done, with copies of recent results, handedness, and the symptoms you’ve noted yourself. On the psychological statement, give the DSM-5 diagnosis and rate each sign and symptom as mild, moderate, or severe. Note any personality disorder, substance use, or gambling problem, related medical conditions and medications, psychosocial problems in the past year, and the GAF scores.
Part 2, Treatment and visits
List each medication with the start date, dose, and frequency. On the psychological statement, record when medication was increased, maximized, or combined, and whether the patient sees a psychiatrist, psychologist, social worker, or another professional, and since when. Note follow-up at a treatment centre, day hospital, or in therapy. On the physical statement, add other treatments, surgery, hospitalization, and specialists.
Part 3, Follow-up and prognosis
Give the date of the last visit, how often you see the patient, and any referrals or scheduled tests. Rate compliance with treatment as excellent, average, or poor. If you expect the absence to run past the usual period for the diagnosis, state the factors your prognosis rests on. This is the question an extension is decided on, so be specific. Estimate the remaining length of disability, or mark indeterminate, and say whether the patient can do their regular work or any other work, with a gradual return plan if you recommend one.
Part 4, Functional capacity or mental impairment ratings
On the physical statement, mark how many hours in an 8-hour workday the patient can sit, stand, and walk, the lifting category that fits, and how often they can grasp, do fine manipulation, type, rotate the shoulder and elbow, and use foot controls on each side. Add any other limitations, and for pregnancy complications, the due date and the medical reasons the patient can’t work. On the psychological statement, rate the 16 abilities from 0 to 4.
Part 5, Identification of the attending physician
Print your name, address, phone, and fax, mark general practitioner, specialist, or other, and sign and date.
Common reasons it’s delayed
- No factors given for a disability that’s running longer than usual.
- Functional capacity or ability ratings left blank.
- Ratings that don’t match the symptoms and examination described.
- Compliance with treatment not answered.
- The member authorization at the top of the physician’s statement unsigned.
- Recent test results or specialist reports not attached.
Submitting and who pays
The member returns the whole document, with no pages detached, to iA’s Disability Claims office in Montreal for Quebec, or in Toronto for all other provinces. The member also encloses benefit statements and correspondence from any government plan paying them. The form states that the member pays any fee for completing it, so bill the patient.