Disability Tax Credit Certificate - Canada Revenue Agency Page 4
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6Protected B
when completed
Patient's name:
Life-sustaining therapy –
Medical doctor or nurse practitioner
(under proposed changes)
Life-sustaining therapy for your patient must meet both of the following criteria:
• your patient needs this therapy to support a vital function, even if this therapy has eased the symptoms; and
• your patient needs this therapy at least 3 times per week, for an average of at least 14 hours per week.
The 14-hour per week requirement
Include only the time your patient must dedicate to the therapy – that is, the patient has to take time away from
normal, everyday activities to receive it.
If a child cannot do the activities related to the therapy because of his or her age, include the time spent by the child's
primary caregivers to do and supervise these activities.
Do not include the time a portable or implanted device takes to deliver the therapy, the time spent on activities related
to dietary restrictions or regimes (such as carbohydrate calculation) or exercising (even when these activities are a
factor in determining the daily dosage of medication), travel time to receive therapy, medical appointments (other than
appointments where the therapy is received), shopping for medication, or recuperation after therapy.
1. Does your patient need this therapy to support a vital function?
Yes
No
2. Does your patient need this therapy at least 3 times per week?
Yes
No
3. Does this therapy take an average of at least 14 hours per week?
Yes
No
Year
If yes, when did your patient's therapy begin to meet the above criteria (this is not necessarily the year of
the diagnosis, as is often the case with progressive diseases)?
It is mandatory that you describe how the therapy meets the criteria as stated above. If you need more space, use a separate sheet of paper,
sign it and attach it to this form.
Cumulative effect of significant restrictions –
Medical doctor, nurse practitioner
,
(under proposed changes)
or occupational therapist
Note: An occupational therapist can only certify limitations for walking, feeding and dressing.
Answer all the following questions to certify the cumulative effect of your patient's significant restrictions.
1. Even with appropriate therapy, medication, and devices, does your patient have a significant restriction, that
Yes
No
is not quite a marked restriction, in two or more basic activities of daily living or in vision and one or more of
the basic activities of daily living?
If yes, tick at least two of the following, as they apply to your patient.
vision
speaking
hearing
walking
eliminating (bowel or bladder functions)
feeding
dressing
mental functions necessary for everyday life
Note
You cannot include the time spent on life-sustaining therapy.
2. Do these restrictions exist together, all or substantially all of the time (at least 90% of the time)?
Yes
No
3. Is the cumulative effect of these significant restrictions equivalent to being markedly restricted in one basic
Yes
No
activity of daily living?
Year
4. When did the cumulative effect described above begin (this is not necessarily the year of the diagnosis, as is
often the case with progressive diseases)?
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