Information for health professionals about Canada Pension Plan disability benefits

Overview

The following information is intended for physicians and nurse practitioners responsible for completing Canada Pension Plan (CPP) disability benefit medical reports and forms.

As a health care 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 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.

The CPP disability benefit provides basic earnings replacement in the form of monthly benefits to Canada Pension Plan contributors who have made the required contributions and are determined incapable of regularly working at any substantially gainful job due to a severe and prolonged physical and/or mental disability. The CPP disability benefit:

  • does not provide additional payments for prescription drugs, medical supplies, assistive devices or other health-related services
  • is not intended for short-term disability coverage
  • automatically changes to a CPP retirement pension at age 65

A separate monthly benefit is paid to a CPP disability recipient’s children under the age of 18, and between the ages of 18 and 25 if the children are in full-time attendance at school or university.

Working with your patient

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 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.

Note: What to write in your medical report

It is not necessary for you to include any particular statements or phrases to ensure that your patient qualifies for benefits. We assess the totality of the evidence, medical and non-medical, to reach our decision and do not base it on whether the physician includes or omits a statement about the patient having a severe and prolonged disability, for example.

Eligibility criteria

To qualify for CPP disability benefits, the applicant must:

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.

For more information on eligibility criteria, visit Canada Pension Plan disability benefit – Eligibility.

Application forms

The application kit for CPP disability benefits is available online or by contacting the CPP Program. The kit includes:

You are responsible for completing the medical report on behalf of your patient. The medical information you provide is critical when we assess an application.

Type of medical information needed

The following information related to an applicant’s medical history is required for the medical report:

  • The medical diagnosis of the physical and/or mental illness(es)
  • The findings upon which the diagnosis was made
  • The resulting physical and/or mental functional limitations or restrictions
  • The date of onset of the limitations or restrictions
  • The prognosis of the medical condition(s)
  • The impacts of treatment(s)
  • Whether the medical condition(s) are episodic, continuous, resolving or unknown

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 the CPP Program if you are not able 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.

Decision-making

Our medical adjudicators are responsible for making decisions on applications for CPP disability benefits and may request additional information. See how applications for disability benefits are assessed.

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.

While medical information is of primary importance, the CPP disability program takes a holistic approach to decision-making. For example, factors such as a person’s age, education, as well as transferable work skills and experiences are considered. However, local socio-economic conditions are not considered.

Applicants who are deemed ineligible for benefits may request an internal review of the initial decision to deny benefits. Subsequently, an applicant who is denied benefits can appeal to the Social Security Tribunal.

Billing

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:

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.

Employment and Social Development Canada  (ESDC) no longer provides copies of 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 the CRA for information for recipients.

Privacy

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.

Retirement pension and disability benefits

If you think a patient might qualify for CPP disability benefits, he or she may want to apply for both a retirement pension and disability benefits at the same time. While a person cannot receive both at the same time, he or she may qualify to begin receiving a retirement pension while waiting for the CPP disability benefit application to be assessed, which usually takes longer. If the patient is already receiving a retirement pension when the application for disability benefits is approved, the CPP disability program will switch the person to disability benefits if he or she:

  • is under the age of 65
  • has earned a specified minimum amount and contributed to the CPP while working for a minimum number of years
  • has been receiving a CPP retirement pension for less than 15 months
  • has been deemed to be disabled, as defined by the CPP legislation, before the effective date of his or her retirement pension

Returning to work

The CPP disability program encourages beneficiaries to work to their potential and offers the following return to work support:

  • Automatic reinstatement is a financial safety net for people receiving CPP disability benefits who try to return to work. If a beneficiary returns to work but is unable to continue working because of the same or a related disability, he or she can ask to have the benefit restarted without having to go through the usual reapplication process
  • The CPP disability program offers vocational rehabilitation for CPP disability beneficiaries who meet the criteria and wish to transition to regular employment
  • CPP disability beneficiaries who are not yet ready to return to regular employment are encouraged to volunteer, attend school and/or participate in training or skills upgrading. These activities do not affect continuing eligibility for benefits or the amount of monthly benefit

Work-related income while receiving CPP disability benefits

Beneficiaries can earn up to an annually determined modest amount before having to advise the CPP disability program of their work-related earnings. For 2017, this amount is $5,500 (before taxes). This level of earnings does not result in cessation of benefits; however, it is a point at which supports and services are offered to help with work efforts.

Returning to CPP disability benefits

You must complete a separate Reinstatement of CPP Disability Benefits Physician Confirmation Form in order to help a patient return to CPP disability benefits. The procedure to obtain payment is shown on the form.

If a patient no longer has the customized form provided when he or she left CPP disability benefits, another can be obtained by contacting Service Canada. The form is not available online.

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