SC ISP-2519, Medical Report for Canada Pension Plan Disability Benefits Completed Form Examples and Samples
Explore a detailed, filled-out example of the SC ISP-2519 Medical Report for Canada Pension Plan Disability Benefits. This sample provides a clear guide for physicians and applicants on how to document medical information, functional limitations, and prognosis to support a CPP-D claim.
SC ISP-2519 Example: Medical Report for CPP Disability Benefits
How this form was filled:
This sample SC ISP-2519 form is completed by a family physician for a patient with severe chronic back pain and secondary depression. It details the diagnoses, functional limitations, treatments, and a guarded prognosis, demonstrating how to provide the necessary medical evidence for a Canada Pension Plan Disability Benefits application.
Information used to fill out the document:
- Patient Name: Emily Carter
- Patient SIN: 123-456-789
- Patient Date of Birth: 1978-06-15
- Primary Diagnosis: Chronic Lumbar Spondylosis with Degenerative Disc Disease at L4-L5, L5-S1.
- Secondary Diagnosis: Major Depressive Disorder, recurrent, moderate, secondary to chronic pain.
- Date Condition Began to Affect Work: October 2023
- Date Patient Ceased to Work: November 30, 2025
- Prognosis: Guarded. The condition is severe and prolonged. Recovery to the point of being able to sustain substantially gainful employment is unlikely.
- Functional Limitations: Unable to sit or stand for more than 20 minutes at a time. Cannot lift more than 5 lbs. Chronic pain (rated 8/10) impairs concentration, memory, and sleep. Requires frequent changes in position.
- Objective Medical Findings: MRI shows advanced degenerative disc disease and spondylosis at L4-S1. Limited lumbar range of motion in all planes. Positive straight leg raise test bilaterally.
- Treatments Tried: Physiotherapy, chiropractic care, NSAIDs, nerve block injections, antidepressants (Cymbalta).
- Physician Name: Dr. Alan Grant
- Physician Specialty: Family Medicine
- Physician License Number: ON-12345
- Date of Report: 2026-01-10
What this filled form sample shows:
- Clear documentation of a 'severe and prolonged' disability, aligning with CPP-D eligibility criteria.
- Detailed description of specific functional limitations that directly impact the capacity to work.
- Inclusion of both a primary physical diagnosis and a significant secondary psychological diagnosis, providing a holistic view of the disability.
- A definitive prognosis from the medical professional indicating the long-term nature of the condition.
- Properly completed physician and patient identification sections for a valid submission to Service Canada.
Form specifications and details:
| Form Number: | SC ISP-2519 |
| Form Title: | Medical Report for Canada Pension Plan Disability Benefits |
| Issuing Agency: | Service Canada / Employment and Social Development Canada |
| Use Case: | Application support for a patient with complex chronic physical and mental health conditions preventing employment. |
Created: February 10, 2026 11:14 PM
