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Initial attending physician statement - 12900E01 - Desjardins Life 2026

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The document outlines the procedures and requirements for submitting disability claims under a group insurance policy. It emphasizes the importance of having the patient's physician complete specific Initial Attending Physician’s Statement forms tailored to various medical conditions, including general, musculo-skeletal, psychiatric/psychological, cardiac, and cancer-related issues. The document provides detailed instructions on how to fill out these forms, where to send them, and the timelines for submission to ensure timely processing of short-term and long-term disability claims.

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Click ‘Get Form’ to open the Initial Attending Physician Statement in the editor.
Begin with Part 1, where the patient must provide their identification details including first and last names, date of birth, address, and contact information.
In Part 2, the physician will complete their statement. They should start by detailing the diagnosis, including any complications and subjective symptoms.
Next, the physician should document the patient's medical history, including dates of symptom onset and treatment history. Ensure all relevant clinical notes are attached.
Continue filling out sections regarding treatment plans, progress assessments, and return-to-work plans. Each section requires specific details about medications and rehabilitation options.
Finally, ensure that both patient and physician sign off on the form before submitting it to Desjardins Financial Security Life Assurance Company.

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What is a physicians statement for life insurance?

This document, which life insurance carriers typically request during the underwriting process, provides detailed medical information from your attending physician and offers insights into your health history, current medical conditions, and past and current treatments.

How to fill out an attending physician statement?

Typically, the APS will request details from your doctor on the following: Your doctors history of treating your condition; Your diagnosis and symptoms; Your prescribed medications; Your treatment plan; Whether or not you are disabled from performing your job duties; The date on which you became disabled;

What does an attending physician statement include?

A typical APS will contain history of any medical conditions and prognosis. The doctor will explain your medical history by noting how long you have been treated, what are the symptoms, and what other treatments you might have had.