SC ISP-2519, Medical Report for Canada Pension Plan Disability Benefits Instructions

Provide any additional medical or contextual details that may help Service Canada assess the patient’s current and future ability to work—such as upcoming tests, specialist referrals, reasons the prognosis is uncertain, frequency of follow-up, or socioeconomic factors impacting return-to-work potential.

Check this box if you are including copies of your longitudinal clinical notes as supporting documents for any of the relevant medical conditions listed in Section 4 or Section 5.

Select this option if you are including medical investigation reports as supporting documents for any of the relevant medical conditions listed in Section 4 or Section 5 of the form.

Check this box if you are including copies of specialist’s report(s) as supporting documents for any of the relevant medical conditions listed in Section 4 or Section 5 of the Medical Report.

Check this box if you are including one or more hospital discharge reports as supporting documentation for any of the medical conditions listed in Section 4 or Section 5 of this Medical Report.

Select this option if you are attaching a type of medical report not covered by the listed categories (longitudinal clinical notes, medical investigation reports, specialist’s reports, or hospital discharge reports), and provide the specific report type on the line provided.

If you are submitting any additional type of medical report that is not covered by the listed options (e.g., rehab progress notes, psychology reports, etc.), briefly describe it here so Service Canada knows what extra documentation accompanies this medical report.

Select this option if the patient has been under your care for one year or less.

Check this box if the patient has been in your care for between one and two years.

Select this option if the patient has been under your care for three to four years.

Select this option if the patient has been under your care for five years or more.

Provide the total count of times the patient has been seen in your office for any reason during the last 12-month period. Enter a whole number only (e.g., 4, 12).

Check this box if you agree to authorize Service Canada to collect medical and other personal information about you from the listed persons and organizations to determine or maintain your eligibility for CPP disability benefits or assess incapacity under the CPP or OAS Act.

Check this box only if you refuse to authorize Service Canada to collect medical and other personal information from all listed persons and organizations to determine or continue your eligibility for CPP disability benefits.

Applicant or legal representative must sign here to validate the consent section. Use your usual handwritten signature. If no value provided, leave empty.

Write the date (YYYY-MM-DD) on which you—or your legal representative—signed the consent in Section 2. The date must not be in the future and should match the day the signature was provided.

Select this option if your preferred courtesy title is “Mr.”

Select this option if your courtesy title is Mrs., indicating you wish to be addressed as Mrs. in Section 1.

Check this box if you wish to be addressed by the title “Miss” in Section 1 of the form.

Check this box if your personal title is Ms. and you wish to use it on this form.

State the primary medical diagnosis being reported on this page (only one condition per page). Use the common clinical term, e.g., "Rheumatoid arthritis."

Provide the ICD-9-CM diagnostic code for the first condition in the required “XXX.X” format (e.g., 714.0).

Enter the year and month when the first symptoms of the first condition began (YYYY-MM). If unsure of the exact day, estimate the month.

Select this option if, in your professional medical judgment, the applicant’s firtst condition is likely to improve over time.

Check this box if, in your professional opinion, the patient’s first medical condition is expected to worsen over time.

Check this box if, in your medical opinion, the patient’s first condition is expected to remain stable (neither improve nor deteriorate).

Check this box if the clinician cannot determine whether the first condition will improve, deteriorate or remain the same (i.e. the prognosis is unknown).

Select this option in row 2 if the patient’s first medical condition is expected to last less than one year.

Select this option if the patient’s first condition is expected to last more than one year.

Check this box if the patient’s first medical condition occurs in recurring or episodic episodes (i.e., intermittently) rather than continuously.

Check this box if the patient’s first condition or symptoms occur continuously (i.e. without episodic breaks).

Check this box when the frequency of the first medical condition cannot be determined (i.e. it is neither clearly recurrent/episodic nor continuous).

Describe the measurable clinical impairments caused by the first condition (e.g., decreased range of motion, muscle weakness, X-ray findings). Provide objective details.

Explain how the first condition impairments restrict the patient’s ability to perform daily or work-related activities (e.g., can stand only 10 minutes, unable to lift >5 kg).

List the first medication prescribed for the first condition, including drug name, strength, total daily dose, and dosing schedule.

Indicate the year and month the above medication was started (or is planned to start).

Enter the year and month the medication was discontinued or is expected to stop. Leave blank if ongoing.

Summarize effectiveness, side effects, adherence issues, or other comments for the first listed medication.

Enter the start date (year-month) for the second medication of the first condition.

Provide the discontinuation/expected end date for the second medication of the first condition, if applicable.

Comment on efficacy, adverse effects, or other observations regarding the second medication of the first condition..

List the second medication for the first condition, including name, strength, and dosing regimen.

Year and month the third medication of the first condition was initiated.

Year-month the third medication of the first condition ended or is expected to end.

Note effectiveness, tolerance, or other relevant information for the third medication of the first condition.

List the third medication (if any) of the first condition with full dosing details.

Describe the first non-drug treatment (e.g., physiotherapy, counselling) of the first condition, including how often it is provided.

Enter the year and month this treatment began.

Provide the year-month the treatment ended or is expected to end.

Summarize outcomes, patient tolerance, or other observations for this treatment of the first condition.

Describe the second non-drug treatment of the first condition and its frequency.

Year-month the second treatment of the first condition started.

Year-month the second treatment of the first condition ended or is expected to end.

Provide information on efficacy or issues observed with the second treatment of the first condition.

Describe any third non-drug treatment of the first condition and how often it is provided.

Year-month the third treatment of the first condition began.

Year-month the third treatment of the first condition ended or is expected to end.

Summarize the patient’s response, benefits, or side effects from the third treatment of the first condition.

Select this option if you prefer to receive all Service Canada correspondence and complete the form in English.

Select this option if you prefer to receive all correspondence and documents from Service Canada in French.

Type your legal first (given) name as it appears on your birth certificate, passport, or other official ID. Do not use nicknames or initials.

If you have one, enter your full middle initial name(s). If you do not have a middle name, leave this field blank.

Enter your current legal last name or family name. If you have multiple family names, type them all exactly as shown on your official documents.

If your last name has changed since birth (e.g., due to marriage, adoption, or legal name change), enter the last name you were given at birth. If it is the same as your current last name, leave blank.

Enter your full mailing address where Service Canada should send correspondence. Include street number and name, apartment or unit number (if any), PO Box or RR number, city/town, province/territory, country (if outside Canada), and postal code.

Enter the most recent date (YYYY-MM-DD) you examined or consulted with the patient, regardless of purpose. Use four-digit year, two-digit month, and two-digit day—for example, 2025-04-18.

Provide the date (YYYY-MM-DD) you began treating the patient specifically for the medical condition that is the basis of the CPP-Disability application. If the exact day is unknown, use the first day of the month (e.g., 2019-05-01).

Record the patient’s current height in centimetres, measured without shoes during the examination.

Record the patient’s current body weight in kilograms, measured at the time of the examination.

Enter your 9-digit Social Insurance Number exactly as it appears on your SIN card or official government documentation. This is required so Service Canada can accurately locate your records and link your disability application to the correct person.

Provide your complete date of birth in the required YYYY-MM-DD format (year-month-day). For example, 1980-07-15.

Enter your 9-digit Canadian Social Insurance Number exactly as it appears on your SIN card or official government record. This uniquely identifies you for CPP disability processing.

Enter your 9-digit Canadian Social Insurance Number exactly as it appears on your SIN card or official documentation. Service Canada uses this number to identify your record and link your CPP disability application to your earnings and contribution history.

Enter the applicant’s 9-digit Social Insurance Number exactly as it appears on their SIN card. This uniquely identifies the patient on every page of the medical report.

Enter the applicant’s 9-digit Social Insurance Number exactly as it appears on their SIN card or official documents. This number uniquely identifies the applicant for Canada Pension Plan purposes.

Enter the applicant’s 9-digit Social Insurance Number exactly as it appears on their SIN card. This uniquely identifies the CPP disability application.

Enter the applicant’s 9-digit Social Insurance Number exactly as it appears on their SIN card (no spaces or dashes). Service Canada uses this to match the medical report to the correct CPP-Disability application.

Enter the applicant’s 9-digit Social Insurance Number exactly as it appears on their SIN card or official documentation. This is used to match this page with the rest of the CPP-D application.

Enter the applicant’s 9-digit Social Insurance Number exactly as it appears on their SIN card or official record. This is used by Service Canada to match the medical report to the correct CPP-Disability application file.

Enter the applicant’s nine-digit Social Insurance Number exactly as it appears on their SIN card or Service Canada letter. This uniquely identifies the CPP-disability claimant.

Provide the main telephone number where Service Canada can reach you during the day. Include the 3-digit area code and 7-digit number. If outside Canada/USA, also include the country code.

Enter an additional telephone number (cell, work, or secondary home line) where you can also be reached. This is optional but recommended in case Service Canada cannot reach you at your primary number.

Print or type your full professional name (first, middle initial, last). This will appear on record as the medical professional completing the report.

Provide complete mailing address (clinic/hospital name, street, city, province, postal code) and a daytime phone number where Service Canada can reach you for clarification or follow-up.

Signature of the specialist (or clinic representative) confirming that the contact details provided above are accurate and that they consent to being contacted by Service Canada.

Enter the date you sign the declaration in ISO format YYYY-MM-DD. This confirms when the medical information was certified.

Select this checkbox if you are a general practice physician or a physician certified in family medicine (CCFP).

Select this option if you are a physician specialist (i.e. not a general practice physician or CCFP-certified family physician); then provide your specialty in the adjacent field.

Check this box if the medical report is being completed by you in your capacity as a nurse practitioner.

Check this box if you are a registered nurse whose practice is located in a geographically isolated community (i.e., neither urban nor rural).

If you are a physician specialist other than family medicine, state your specialty here (e.g., neurologist, rheumatologist). This clarifies your professional qualification when certifying the report.

Select this option if the morning is the best time for Service Canada to contact you.

Check this box if you prefer Service Canada to contact you in the afternoon.

Check this box if you do not wish to receive phone calls from Service Canada and prefer to receive all correspondence by mail.

In table row 2, check this box if the patient’s condition is expected to last more than one year.

Check this box if you expect the patient’s medical condition to worsen (deteriorate) over time.

In table row 1 (Prognosis), check this box if the condition is expected to remain the same (i.e. neither improve nor deteriorate).

Select this option if you are unable to determine whether the patient’s condition will improve, deteriorate or remain the same (i.e. the prognosis is unknown).

Check this box if the applicant’s medical condition is expected to worsen or deteriorate over time.

Select this option if the applicant’s medical condition is likely to deteriorate over time.

Check this box if, in your professional opinion, the patient’s medical condition is expected to worsen (deteriorate) over time.

Check this box if the medical condition is expected to worsen or decline over time (i.e., to deteriorate).

Check this box if the patient’s condition is likely to improve (Table row 4: Prognosis).

Select this option in table row 4 under “Prognosis” if the patient’s medical condition is expected to deteriorate over time.

Check this box if the medical condition’s expected duration is more than one year.

In the Prognosis section (row 1), check this box if the practitioner cannot predict whether the applicant’s condition will improve, deteriorate or remain the same (prognosis is unknown).

Select this option if the patient’s condition is expected to worsen or deteriorate over time.

Check this box if the patient’s medical condition is expected to worsen (deteriorate) over time.

Check this box if you assess that the claimant’s condition is likely to deteriorate over time (table row 1).

In table row 3 (Prognosis), check this box if the patient’s condition is expected to deteriorate (worsen) over time.

Select this option if you expect the patient’s condition to worsen over time

Check this box if you have advised the patient to cease working.

Select this box if you did not recommend that the patient stop working.

Select this box if you did not discuss with the patient whether they should stop working.

If you advised the patient to cease employment, type the exact calendar date you gave that recommendation in the format YYYY-MM-DD (e.g., 2025-03-14). Leave blank if you did not recommend stopping work.

Select this option if, from a strictly medical standpoint, you expect the patient to return to any type of work in the future. If checked, proceed to complete questions 3 and 4; otherwise skip to Section 7.

Check this box if, from a strictly medical standpoint, you do not expect your patient to return to any type of work in the future.

Select this option if, from a strictly medical standpoint, you cannot determine whether the patient will ever be able to return to any type of work.

Select this option if, from a strictly medical standpoint, you expect your patient to be able to return to any type of work within 6 to 12 months.

Select this option if, from a strictly medical standpoint, you expect your patient to be able to return to any type of work in 12 to 24 months

Check this box if, from a strictly medical standpoint, you expect the patient to be able to return to any type of work only after more than 24 months.

Select this option if you expect the patient to return to any type of work in the future but cannot estimate when that return will occur.

State the main diagnosed medical condition(s) for which the disability benefit is being requested. Use the precise clinical term(s) (e.g., ‘severe osteoarthritis of left hip’).

Provide the corresponding ICD-9-CM diagnostic code in the format XXX.X. If the condition has more than one applicable code, enter the principal one.

Record the year and month when the first symptoms of the second medical condition appeared or were first noticed by the patient.

Check this box if, in your medical opinion, the applicant’s second condition is expected to improve over time.

Check this box if, for the second listed medical condition, the patient’s prognosis is that the condition is likely to deteriorate (worsen) over time.

Check this box if, based on your medical judgment, the patient’s second condition is expected to remain the same over time.

Select this checkbox in when the medical practitioner cannot determine whether the patient’s second condition is likely to improve, deteriorate, or remain the same (prognosis unknown).

Check this box if the second medical condition is expected to last less than one year.

Check this box if the patient’s second medical condition is expected to last for more than one year.

Check this box if the patient’s second condition occurs in a recurrent or episodic pattern (i.e. comes and goes) rather than being continuous or of unknown frequency.

Check this box if the patient’s second condition is ongoing continuously (i.e. without remission or episodic/recurrent patterns).

Select this box when the frequency of the second medical condition cannot be determined (i.e., it is neither recurrent/episodic nor continuous).

Describe the measurable clinical impairments caused by the second condition (e.g., limited range of motion 30°, visual acuity 20/200, LVEF 35%). List all that apply.

Explain how the impairments restrict the patient’s ability to perform daily or work-related activities (e.g., cannot stand >10 min, unable to lift >5 kg, needs assistance dressing).

If second condition is provided, enter the first prescribed medication’s generic or brand name along with dose and how often it is taken.

If second condition is provided, Provide the year and month (YYYY-MM) when Medication 1 was first prescribed or is planned to start.

If second condition is provided, Indicate the actual or estimated year and month (YYYY-MM) when Medication 1 was or will be discontinued. Leave blank if ongoing.

If second condition is provided, Note the treatment response, side-effects, adherence issues, or any other clinically relevant comments for Medication 1.

If second condition is provided, Provide the start date (YYYY-MM).

If second condition is provided, Enter the stop date (YYYY-MM) or expected completion date of medication 2. Leave blank if ongoing.

If second condition is provided, Summarize effectiveness, adverse reactions, or other observations for medication 2.

If second condition is provided, Enter the second prescribed medication’s name, dosage, and administration schedule.

If second condition is provided, Provide the start date (YYYY-MM) for Medication 3.

If second condition is provided, State the end or expected end date (YYYY-MM) for Medication 3, or leave blank if still prescribed.

If second condition is provided, Document any observed efficacy, tolerance issues, or additional notes for Medication 3.

If second condition is provided, Enter the third medication’s name, dose, and frequency, if applicable.

If second condition is provided, Specify the first non-pharmacological treatment (e.g., physiotherapy, CBT, surgery) and how often it is administered.

If second condition is provided, Enter the year and month (YYYY-MM) when Treatment 1 began or is planned to begin.

If second condition is provided, Provide the actual or expected completion date (YYYY-MM) for Treatment 1, or leave blank if ongoing.

If second condition is provided, Describe the outcome, benefits, side-effects, or any pertinent notes regarding Treatment 1.

If second condition is provided, List the second non-pharmacological treatment and its frequency, if applicable.

If second condition is provided, Enter the start date (YYYY-MM) for treatment 2.

If second condition is provided, Provide the end or expected end date (YYYY-MM) for treatment 2 or leave blank if still underway.

If second condition is provided, Summarize effectiveness, complications, or other comments for treatment 2.

If second condition is provided, Describe a third treatment method and how often it is provided, if applicable.

If second condition is provided, Enter the start date (YYYY-MM) for Treatment 3.

If second condition is provided, State the end or projected end date (YYYY-MM) for Treatment 3, or leave blank if ongoing.

If second condition is provided, Provide information on results, side-effects, or any relevant notes for Treatment 3.

Check this box if the patient’s medical condition is terminal, defined as a disease state that cannot be cured or adequately treated and is reasonably expected to result in death within 6 months.

If 'Terminal Condition' is selected, State the precise medical diagnosis (expected to result in death within 6 months). Use the full medical term, e.g., "Stage IV pancreatic adenocarcinoma."

If 'Terminal Condition' is selected, Provide the corresponding 4- or 5-digit ICD-9-CM diagnostic code for the terminal condition. This standard code is required for consistent medical classification.

If 'Terminal Condition' is selected, Enter the year and month when the first symptoms of the diagnosed terminal condition appeared (format: YYYY-MM). If the exact day is unknown, leave it blank—only year and month are required.

Check this box if the patient’s condition is grave (i.e. meets the definition of a severe and rapidly progressive medical condition listed in Annex A); if checked, provide full details in Section 5.

Check this box if the patient does not have a terminal or grave condition expected to cause death within six months.

Write the name of the third medical condition (e.g., ‘Rheumatoid arthritis’, ‘Major depressive disorder’). Use plain language; avoid abbreviations unless they are standard.

Provide the 3- to 4-digit ICD-9-CM diagnostic code that corresponds to the third medical condition (e.g., 714.0). Use a leading zero if required.

Enter the first month and year (YYYY-MM) the patient began experiencing symptoms related to the third condition.

Select this box if the patient’s third condition occurs in recurring or episodic flare-ups rather than as a continuous condition.

Select this option if the third medical condition is present continuously (i.e. constant, without recurrent or episodic intervals).

Check this box if you are unable to determine whether the third condition occurs recurrently/episodically or continuously (i.e. the frequency of the condition is unknown).

Describe the objective physical, mental, or sensory impairments caused by the third condition (e.g., reduced grip strength, limited range of motion, memory deficits). Use clinical wording and measurement where possible.

Explain how the third condition impairments limit the patient’s ability to perform daily or work-related activities (e.g., ‘cannot lift more than 5 kg’, ‘unable to concentrate for more than 15 minutes’).

If third condition is provided, List the first medication currently or previously prescribed, including exact dose and how often it is taken (e.g., ‘Methotrexate 20 mg once weekly’).

If third condition is provided, Provide the actual or proposed start date (YYYY-MM) for the first medication.

If third condition is provided, If the first medication has stopped or is expected to stop, enter the actual or estimated end date (YYYY-MM). Leave blank if ongoing.

If third condition is provided, Note the patient’s response, any side-effects, or other relevant comments about the first medication.

If third condition is provided, Enter details for a second medication, if applicable.

If third condition is provided, Enter the actual or proposed start date (YYYY-MM) for the second medication .

If third condition is provided, Enter the actual or estimated end date (YYYY-MM) for the second medication, or leave blank if still prescribed.

If third condition is provided, Record efficacy, side-effects, or other observations about the second medication.

If third condition is provided, Enter details for a third medication, if applicable.

If third condition is provided, Enter the actual or proposed start date (YYYY-MM) for the third medication.

If third condition is provided, Enter the actual or estimated end date (YYYY-MM) for the third medication or leave blank if ongoing.

If third condition is provided, Document the patient’s response, side-effects, or other relevant notes about the third medication.

If third condition is provided Describe the first non-pharmacological treatment (e.g., physiotherapy, counselling) and how often it occurs.

If third condition is provided, Enter the actual or proposed start date (YYYY-MM) for the first treatment.

If third condition is provided, Enter the actual or estimated end date (YYYY-MM) for the first treatment, or leave blank if ongoing.

If third condition is provided, Note the effectiveness, tolerance, or any notable comments regarding the first treatment.

If third condition is provided, Describe a second non-pharmacological treatment, if applicable.

If third condition is provided, Enter the actual or proposed start date (YYYY-MM) for the second treatment.

If third condition is provided, Enter the actual or estimated end date (YYYY-MM) for the second treatment, or leave blank if ongoing.

If third condition is provided, Record the patient’s response or other relevant comments about the second treatment.

If third condition is provided, Describe a third non-pharmacological treatment, if applicable.

If third condition is provided, Enter the actual or proposed start date (YYYY-MM) for the third treatment.

If third condition is provided, Enter the actual or estimated end date (YYYY-MM) for the third treatment, or leave blank if ongoing.

If third condition is provided, Document efficacy, side-effects, or other observations regarding the third treatment.

In row 1 of the Prognosis table, select this option if, in your professional opinion, the patient’s third medical condition is likely to improve over time.

Check this box if the patient’s third medical condition is expected to worsen (deteriorate) over time.

In table row 1, check this box if you expect the patient’s third condition to remain stable (neither improve nor deteriorate).

Check this box if the clinician cannot determine whether the patient’s third condition is likely to improve, deteriorate or remain the same (i.e. prognosis is unknown).

Select this checkbox if you anticipate the third medical condition’s expected duration will be less than one year.

Check this box if the patient’s third medical condition is expected to last more than one year.

Select this option if you expect your patient will be able to return to their usual work duties without any modifications.

Select this option if you expect your patient will be able to return to a modified type of work

Check this box when you expect your patient will be able to return to work only in a different type of job for which they will need additional training.

Check this option when the patient’s future work capacity will involve a type of work not covered by “Usual work,” “Modified work,” or “Another type of work that will require training,” and specify the alternative work type in the space provided.

If you believe the patient could eventually perform a different kind of job that is not their usual work, a modified version of it, or another job requiring formal training, describe that job or work setting here (e.g., ‘part-time sedentary office duties’). Leave blank if not applicable.

If you signed the consent with a mark (e.g., X) rather than a written signature, a witness is required. The witness must print their first (given) name here.

If applicable, the witness prints their middle name(s). Leave blank if the witness has no middle name.

The witness prints their family/last name here. This is mandatory whenever a witness is required.

Provide a telephone number (including area code) where the witness can be reached in case Service Canada needs to confirm the witnessing of the mark signature.

Witness must sign here to confirm they observed the applicant’s mark or signature. If no signature provided, leave empty.

The witness enters the date (YYYY-MM-DD) on which they witnessed the applicant’s mark and signed this form. This date should be the same day the mark was made.