Canada Pension Plan disability benefits: Information for health care professionals

From: Employment and Social Development Canada

COVID-19

Due to the coronavirus disease (COVID-19) outbreak, there are changes to this program.

Health care professionals may need to provide medical details for those applying for Canada Pension Plan (CPP) disability benefits. The information you provide enables Service Canada to assess your patient's eligibility or continued eligibility for benefits.

A patient’s eligibility is based on multiple 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
prognosis
age, education and work history
work performance and productivity

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

Medical report

As a medical professional, you are responsible for completing and submitting the medical report or terminal illness medical attestation on behalf of your patient. The decision to grant a disability pension cannot be made until your report is received.

Medical Report for a Canada Pension Plan disability benefit (ISP-2519) (completed by the applicant's physician or nurse practitioner).

Submit the report

Please submit reports promptly to the Service Canada office on the Medical report form

If you are not able to provide the medical information requested, contact the CPP Program. This will help prevent delays in determining your patient’s eligibility.

If your patient has a terminal illness

For the purposes of CPP, a terminal medical condition is a disease state that cannot be cured or adequately treated and is reasonably expected to result in death within 6 months.

If your patient has a terminal illness, please complete a Terminal Illness Medical Attestation. Terminal illness applications receive priority handling.

Terminal Illness Medical Attestation for a Disability Benefit Under the Canada Pension Plan (ISP-2530B) (completed by the applicant’s physician or nurse practitioner)

Type of medical information needed

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. It is not necessary for you to include any particular statements or phrases to ensure that your patient qualifies for benefits.

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

the medical conditions, impairments, functional limitations, prognosis and treatment
the impact of current and future restrictions on the applicant’s ability to work
planned investigations and specialist consultations
supporting documents (that is clinic notes, medical investigation report(s), specialist’s report(s) or hospital discharge reports)

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.

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
diagnostic test results
investigative reports
hospital notes

Can I send clinical notes

If your clinical notes address all the questions in the medical report, you may send those notes instead of completing the entire medical report. However, you must also complete these 2 sections of the medical report:

Section 5 – Medical conditions, impairments functional limitations and treatment of the report
Section 9 – sign the declaration

Sending in your clinical notes is appropriate only for patients you are following closely and for whom you are keeping detailed clinical notes.

Late CPP disability applications

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

Additional requirements of medical professional

The medical information you submit is essential at the initial application, but also during appeals, follow-up reviews, reassessments or vocational rehabilitation.

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 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.

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.

Billing

You must mail your invoice to the Service Canada office address noted on the medical 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 (ISP-2519)
$85 for the Terminal Illness Medical Attestation for a Disability Benefit Under the Canada Pension Plan (ISP-2530B)
$25 for the Reassessment Medical Report (ISP-2509)
$50 for the Scannable Impairment Evaluation (IMPAIR)
$25 for the Medical Report - Recurrence of the Same Medical Problem (ISP-2525)
$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.

Payment for consultations or functional capacity evaluations

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.

T1204 tax slips for service providers

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.

If your patient is returning to work

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

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 automatically 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 2020, this amount is $5,800 (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.

If your patient is 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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