Disability Tax Credit Certificate - Canada Revenue Agency Page 2
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Help
Protected B
Patient's name:
when completed
Part B – Must be filled out by the medical practitioner
Step 1 – Fill out only the section(s) on pages 2 to 4 that apply to your patient. Each category states which medical practitioner(s) can certify
the information in this part.
Note
Whether filling out this form for a child or an adult, assess your patient compared to someone of similar age with no impairment.
Step 2 – Fill out the "Effects of impairment", "Duration", and "Certification" sections on page 5. If more information is needed, the
Canada Revenue Agency (CRA) may contact you.
Eligibility for the DTC is based on the effects of the impairment, not on the medical condition itself. For definitions and examples of impairments
that may qualify for the DTC, see Guide RC4064, Disability-Related Information. For more information, go to
cra.gc.ca/dtcmedicalpractitioners.
Vision –
Medical doctor, nurse practitioner
, or optometrist
(under proposed changes)
Your patient is considered blind if, even with the use of corrective lenses or medication:
• the visual acuity in both eyes is 20/200 (6/60) or less, with the Snellen Chart (or an equivalent); or
• the greatest diameter of the field of vision in both eyes is 20 degrees or less.
1. Is your patient blind, as described above?
Yes
No
Year
If yes, when did your patient become blind (this is not necessarily the year of the diagnosis, as is often the case
with progressive diseases)?
Right eye
Left eye
2. What is your patient's visual acuity after correction?
Right eye
Left eye
3. What is your patient's visual field after correction (in degrees if possible)?
Speaking –
Medical doctor, nurse practitioner
, or speech-language pathologist
(under proposed changes)
Your patient is considered markedly restricted in speaking if, even with appropriate therapy, medication, and devices:
• he or she is unable or takes an inordinate amount of time to speak so as to be understood by another person
familiar with the patient, in a quiet setting; and
• this is the case all or substantially all of the time (at least 90% of the time).
Is your patient markedly restricted in speaking, as described above?
Yes
No
If yes, when did your patient's restriction in speaking become a marked restriction (this is not necessarily
Year
the year of the diagnosis, as is often the case with progressive diseases)?
Hearing –
Medical doctor, nurse practitioner
, or audiologist
(under proposed changes)
Your patient is considered markedly restricted in hearing if, even with appropriate devices:
• he or she is unable or takes an inordinate amount of time to hear so as to understand another person familiar
with the patient, in a quiet setting; and
• this is the case all or substantially all of the time (at least 90% of the time).
Is your patient markedly restricted in hearing, as described above?
Yes
No
If yes, when did your patient's restriction in hearing become a marked restriction (this is not necessarily
Year
the year of the diagnosis, as is often the case with progressive diseases)?
Walking –
Medical doctor, nurse practitioner
, occupational therapist, or physiotherapist
(under proposed changes)
Your patient is considered markedly restricted in walking if, even with appropriate therapy, medication, and devices:
• he or she is unable or takes an inordinate amount of time to walk; and
• this is the case all or substantially all of the time (at least 90% of the time).
Is your patient markedly restricted in walking, as described above?
Yes
No
If yes, when did your patient's restriction in walking become a marked restriction (this is not necessarily the year
Year
of the diagnosis, as is often the case with progressive diseases)?
2
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