SC ISP-2519, Medical Report for Canada Pension Plan Disability Benefits Completed Form Examples and Samples
Explore comprehensive examples and samples of a completed SC ISP-2519, the Medical Report for Canada Pension Plan Disability Benefits. Our filled-out templates demonstrate how to properly document various medical conditions, functional limitations, and prognoses to support a CPP disability claim.
SC ISP-2519 Example: Medical Report for CPP Disability (Depression & Anxiety)
How this form was filled:
This example shows a completed SC ISP-2519 form for a patient with severe, treatment-resistant Major Depressive Disorder, Generalized Anxiety Disorder, and Chronic Fatigue Syndrome. The report details the diagnoses with ICD-10 codes, outlines significant functional limitations affecting work capacity, documents a history of treatments, and provides a guarded prognosis, stating the disability is severe and prolonged.
Information used to fill out the document:
- Patient's Name: Jane Smith
- Patient's Date of Birth: 1978-06-15
- Patient's Last Day of Work: 2025-02-10
- Physician's Name: Dr. Alan Turing, MD
- Physician's Specialty: Family Medicine
- Date of Report: 2026-05-20
- Primary Diagnosis: Major Depressive Disorder, Recurrent, Severe (ICD-10: F33.2)
- Secondary Diagnoses: Generalized Anxiety Disorder (ICD-10: F41.1), Chronic Fatigue Syndrome (ICD-10: G93.3)
- Date of First Consultation for Condition: 2022-03-05
- Key Functional Limitations: Severely impaired concentration, memory, and decision-making; persistent and overwhelming fatigue; inability to manage stress or deadlines; marked social withdrawal.
- Prognosis: Guarded. The disability is considered severe and prolonged. The patient is unlikely to be able to return to any form of substantially gainful employment in the foreseeable future.
- Treatment History: Multiple SSRI/SNRI trials (Sertraline, Venlafaxine), cognitive-behavioral therapy (CBT), referral to psychiatry (ongoing).
What this filled form sample shows:
- Provides specific medical diagnoses with corresponding ICD-10 codes, as required.
- Clearly documents the patient's functional limitations and their direct impact on the ability to work.
- Includes a detailed prognosis that uses the key terms 'severe' and 'prolonged' to describe the disability.
- Summarizes the patient's clinical findings and treatment history to demonstrate that various medical interventions have been attempted.
Form specifications and details:
| Form Number: | SC ISP-2519 |
| Form Name: | Medical Report for Canada Pension Plan Disability Benefits |
| Issuing Agency: | Service Canada / Employment and Social Development Canada |
| Use Case: | Patient with severe, long-term mental health and chronic fatigue conditions preventing any gainful occupation. |
Created: February 05, 2026 08:08 PM
