Submit online: By mail: By fax:
desjardinslifeinsurance.com/send C. P. 3875 succ. Lévis 1-844-409-6575 (toll free)
Complete and save the form on your computer first. Lévis (Québec) G6V 0A7 418-835-0194
Keep original forms for your records. Send original forms and keep copies Keep original forms for your records.
for your records.
INITIAL ATTENDING PHYSICIAN’S STATEMENT
FOR PHYSICAL ILLNESSES
To submit online. Complete and save the form on your computer first. Keep original forms for your records.
To submit by mail: CP 3875 succursale Lévis Lévis Québec G 6 V 0 A 7. Send original forms and keep copies for your records.
Desjardins Insurance life health retirement logo To submit by fax: 4 1 8 8 3 5 0 1 9 4 or toll free 1 8 4 4 4 0 9 6 5 7 5 Keep original forms for your records.
Fédération des médecins omnipraticiens du Québec logo
Regroupement des assureurs de personnes à charte du Québec logo Note: For psychological illnesses, complete the form on the reverse.
1. Identification of the employee - This section must be completed by the employee.
Last name and first name Policy or group or contract no. Certificate or identification no. Date of birth
YYYY MM DD
2. Diagnosis - Complete in block letters and give to the employee.
2.1 Principal: 2.2 Secondary:
2.3 Complications:
2.4 For the illnesses or associated symptoms diagnosed, has the patient previously:
received medical treatments consulted another physician taken drugs been hospitalized undergone examinations
Specify the periods:
2.5 Is the disability related to: An accident An illness
YYYY MM DD
Date of the event:
An occupational accident An automobile accident
A pregnancy A preventive withdrawal from work Scheduled date of delivery: YYYY MM DD
2.6 Describe functional limitations that prevent the patient from carrying out professional duties or usual activities.
At the beginning of disability: YYYY MM DD :
Currently:
3. Treatment
3.1 Drugs – name – dosage:
3.2 Has the patient undergone or will undergo:
a) examinations or tests No Yes Specify:
b) surgery No Yes Day surgery Type: Date: YYYY MM DD
Surgical procedure:
c) other treatments No Yes Specify:
d) hospitalization: From YYYY MM DD To YYYY MM DD Name of hospital:
e) a short stay under observation No Yes Number of hours:
4. Follow-up and prognosis
4.1 Date of first consultation for this disability: YYYY MM DD Next consultation: YYYY MM DD
4.2 Dates of other consultations: Follow-up frequency:
4.3 Referral to another physician: No Yes Name of physician:
Specialty:
4.4 Approximate duration of disability: No. of days: No. of weeks: Unspecified or date of return to work:
4.5 How long before the patient will be able to return to work? No. of days: No. of weeks:
Part-time Full-time Gradual return Specify:
5. Additional information - Please use a separate sheet if necessary.
6. Identification of the physician
6.1 Family name, given name: Telephone: ( ) Fax: ( )
6.2 License number: General practitioner Specialist Specify:
Signature: Date:
NOTE: THE EMPLOYEE MUST PAY THE FEES REQUESTED TO COMPLETE THIS FORM.
02025A (2018-09)
PRINT NEW REQUEST
Information about your diagnosis should be provided by your attending physician. Therefore this section is non fillable online.
Submit online: By mail: By fax:
desjardinslifeinsurance.com/send C. P. 3875 succ. Lévis 1-844-409-6575 (toll free)
Complete and save the form on your computer first. Lévis (Québec) G6V 0A7 418-835-0194
Keep original forms for your records. Send original forms and keep copies Keep original forms for your records.
for your records.
INITIAL ATTENDING PHYSICIAN’S STATEMENT
FOR PSYCHOLOGICAL ILLNESSES
To submit online. Complete and save the form on your computer first. Keep original forms for your records.
To submit by mail: CP 3875 succursale Lévis Lévis Québec G 6 V 0 A 7. Send original forms and keep copies for your records.
To submit by fax: 4 1 8 8 3 5 0 1 9 4 or toll free 1 8 4 4 4 0 9 6 5 7 5 Keep original forms for your records.
Desjardins Insurance life health retirement logo Regroupement des assureurs de personnes à charte du Québec logo
Fédération des médecins omnipraticiens du Québec logo Note: For physical illnesses, complete the form on the reverse.
1. Identification of the employee - This section must be completed by the employee.
Last name and first name Policy or group or contract no. Certificate or identification no. Date of birth
YYYY MM DD
2. Diagnosis - Complete in block letters and give to the employee.
2.1 Principal:
2.2 Secondary:
2.3 Current symptoms:
2.4 Degree of severity of all symptoms: Mild Moderate Severe With psychotic elements
2.5 Does the interruption of work result from problems related to:
Marital/family life Loss of employment or layoff Professional problems
Personal or interpersonal problems Alcohol or drug abuse or gambling problems
Other problems, specify:
2.6 For the illnesses or associated symptoms diagnosed, has the patient previously:
received medical treatments consulted another physician taken drugs been hospitalized undergone examinations
Specify the dates of previous episodes:
3. Treatment
3.1 Drugs – name – dosage:
3.2 Is the patient consulting: a psychiatrist a psychologist a social worker another health care provider
If yes, name of the caregiver consulted:
3.3 Hospitalization: From:
YYYY MM DD YYYY
To: MM DD Name of hospital:
4. Follow-up and prognosis
4.1 Date of first consultation for this disability: YYYY MM DD Next consultation: YYYY MM DD
4.2 Dates of other consultations:
4.3 Follow-up frequency:
4.4 Will the patient be referred to a psychiatrist? No Yes Name of physician:
4.5 Approximate duration of disability: No. of days: No. of weeks: Unspecified or date of return to work:
4.6 How long before the patient will be able to return to work? No. of days: No. of weeks:
Part-time Full-time Gradual return Specify:
5. Additional information - Please use a separate sheet if necessary.
6. Identification of the physician
6.1 Family name, given name: Telephone: ( ) Fax: ( )
6.2 License number: General practitioner Specialist Specify:
Signature: Date:
NOTE: THE EMPLOYEE MUST PAY THE FEES REQUESTED TO COMPLETE THIS FORM.
PRINT NEW REQUEST
Information about your diagnosis should be provided by your attending physician. Therefore this section is non fillable online
