Disability Tax Credit Certificate - Canada Revenue Agency Page 5
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6Protected B
when completed
Patient's name:
Effects of impairment – Mandatory
The effects of your patient's impairment must be those which, even with therapy and the use of appropriate devices and medication, cause
your patient to be restricted all or substantially all of the time (at least 90% of the time).
Note
Working, housekeeping, managing a bank account, and social or recreational activities are not considered basic activities of daily living.
Basic activities of daily living are limited to walking, speaking, hearing, dressing, feeding, eliminating (bowel or bladder functions), and
mental functions necessary for everyday life.
It is mandatory that you describe the effects of your patient's impairment on his or her ability to do each of the basic activities of daily living
that you indicated are or were markedly or significantly restricted. If you need more space, use a separate sheet of paper, sign it and attach it
to this form. You may include copies of medical reports, diagnostic tests, and any other medical information, if needed.
Duration – Mandatory
Has your patient's impairment lasted, or is it expected to last, for a continuous period of at least
12 months? For deceased patients, was the impairment expected to last for a continuous period
Yes
No
of at least 12 months?
If yes, has the impairment improved, or is it likely to improve, to such an extent that the patient
would no longer be blind, markedly restricted, in need of life-sustaining therapy, or have
Unsure
Yes
No
the equivalent of a marked restriction due to the cumulative effect of significant restrictions?
Year
If yes, enter the year that the improvement occurred or may be expected to occur.
Certification – Mandatory
1. For which year(s) have you been the attending medical practitioner for your patient?
2. Do you have medical information on file supporting the restriction(s) for all the year(s) you certified
Yes
No
on this form?
Tick the box that applies to you:
Medical doctor
Nurse practitioner
Optometrist
Occupational therapist
Audiologist
Physiotherapist
Psychologist
Speech-language pathologist
As a medical practitioner, I certify that the information given in Part B of this form is correct and complete. I understand that this information
will be used by the CRA to make a decision if my patient is eligible for the DTC.
Address
Sign here:
It is a serious offence to make a false statement.
Name (print)
Year
Month
Day Telephone
Date:
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