Canada Pension Plan Disability Benefit - Information for health professionals

Information for health professionals about disability benefits

Employment and Social Development Canada (ESDC) no longer provides copies of the T1204 tax slips to service providers. ESDC will however continue to submit all T1204 information to the Canada Revenue Agency (CRA) as required. Refer to CRA for Information for recipients.

As a health professional you play a key role in our process. You may be asked to provide medical information about a patient of yours who has submitted an application for Canada Pension Plan (CPP) disability benefits. This crucial information enables Service Canada to assess your patient's eligibility or continued eligibility.

If required, we may also seek information from specialists or obtain a second opinion from an independent medical examiner.

How do I help my patient get disability benefits?

The medical information you submit about your patient's capacity to work is essential, not only at the initial application level, but also during appeals, follow-up reviews, reassessments, or vocational rehabilitation. We need to have enough information to be reasonably satisfied that your patient meets the eligibility requirements for CPP disability benefits.

What we need from you is a clear and comprehensive medical assessment of your patient's disabling condition, together with information about any limitations on the person’s capacity to function.

One thing you can do to help your patient is to submit the medical report promptly. The decision to grant a disability pension cannot be made until your report is received.

Who makes the decision?

Our medical adjudicators are responsible for making decisions on applications for CPP disability benefits. See how applications for disability benefits are assessed.

Medical eligibility

To be eligible for CPP disability benefits, your patient must have a physical or mental impairment that is both severe and prolonged prevents them from working at any job.

However, eligibility is determined on the basis of other factors in addition to the medical diagnosis. Our medical adjudicators consider the entire individual, including:

• the nature and severity of their medical condition
• the impact of the medical condition and treatment on their capacity to work
• their prognosis
• personal characteristics such as age, education and work history
• their work performance and productivity.

Under CPP legislation, the medical adjudicators do not consider the availability of suitable employment in the applicant's region when determining eligibility.

See other eligibility criteria for CPP disability benefits.

What type of medical information is needed?

The medical information you provide is critical when we assess an application.

We do not need your patient's entire medical file. Provide only the medical information relevant to your patient's capacity to work, including supporting documents such as:

• consultants' reports
• investigative reports
• hospital notes.

If your patient can still work on a regular basis, they will not likely qualify for CPP disability benefits.

If your clinical notes address all the questions in the medical report, you may send those notes instead of completing the entire medical report (which will have been sent to you to fill out).

However, you must complete the prognosis section of the report and sign the form. Sending in your clinical notes is appropriate only for patients you are following closely and for whom you are keeping detailed clinical notes.

We ask that you address the psycho-social impacts of the disability on your patient's capacity to work. Please provide supporting documents for your comments as this will greatly assist us in making a decision.

In the case of a late application, we may ask you for information going back a number of years. With the appropriate information, we can treat an application as though it were submitted at an earlier date, when the applicant met the eligibility requirements. We need to determine whether your patient can be considered to have been medically eligible from that date continuously to the present time.

Contact us if you are unable to provide the medical information requested. This will help prevent delays in determining your patient’s eligibility. We may be able to get information from your patient or from other sources, or we may decide to send your patient for an independent medical consultation.

Will I be asked for any follow-up information?

Yes. As the treating health professional, you are very important in helping us determine whether your patient should continue to receive a disability benefit, or whether they might be eligible for the CPP Disability Vocational Rehabilitation Program.

We periodically review a client's case to ensure continuing eligibility, and we may ask you for up-to-date medical information on your patient's condition. If so, you may be asked to complete a short medical report. To avoid delays for your patient, please answer all the questions on any forms you are asked to fill out.

Our periodic reviews give us an opportunity to make contact with clients and identify what services would suit them best. If your patient's case is being reviewed, your patient will also be asked to provide medical and non-medical information. Because everyone's medical condition is unique, each case is looked at individually. Once all the necessary information has been collected, a decision to continue or stop disability benefits is made.

Can my patient see my medical report?

Yes. The personal information of patients is administered pursuant to the CPP legislation as well as the Access to Information Act and the Privacy Act, under which applicants have the right to formally request a copy of their CPP disability file, including the medical reports and supporting documents.

Appropriate exemption to the release of information may be applied if release of medical information is considered to be contrary to the best interest of the individual (section 28 of the Privacy Act).

If you feel it would be detrimental to your patient to be given particular information about their medical condition, indicate it in your report. We will contact you directly to determine whether this information can be withheld or not.

How will I be paid?

You must mail your invoice to the Service Canada office address noted on the application form. Payment will be made by cheque and mailed to the address noted on the invoice.

Your invoice must include:

• your patient's name
• your patient's address, date of birth or social insurance number (SIN)
• your business number, GST/HST number or SIN.

Service Canada will pay you up to:

• $85 for the initial medical report
• $25 for the reassessment medical report
• $50 for the "Scannable Impairment Evaluation"
• $25 for the "Medical Report - Recurrence of the Same Medical Problem"
• $150 if we ask you to provide other information in the form of a narrative report (depending on the complexity and the time required for completion).

Your patient is responsible for covering any extra costs. Fees outlined in this section are set in consultation with the Canadian Medical Association, and are subject to change.

Occasionally, we may request independent medical consultations or functional capacity evaluations during the initial application process, or when determining continuing eligibility.

We pay the specialist or functional capacity evaluation facility directly for these examinations.