DR. DOCTOR November 09, 2017
321 MAIN STREET
OTTAWA ON K0A 1L0 Processing Number
8917 205 25

Dear Doctor

Re: Jane Smith

Date of birth: 1960-01-01

Our file #: TB4321 4321 4321

We are reviewing a claim for the disability tax credit (DTC) for

your patient, and we need more information to help us with our

review.

The information you provide is CONFIDENTIAL and used solely to

determine if your patient is eligible for the DTC. The ORIGINAL

questionnaire should be directly returned to the Canada Revenue

Agency when completed.

Please answer the following additional questions based on your

professional opinion and knowledge of your patient's medical

condition.

Please note that answering Yes or No is not sufficient to allow us

to determine eligibility. Please provide examples specific to your

patient, as indicated under each question.

LIFE-SUSTAINING THERAPY

Please note that activities such as meal planning and

preparation, shopping for food, carbohydrate calculation, and

choosing foods with a low glycemic index are considered part of a

dietary regime, and should NOT be counted as part of the time

needed for this therapy.

Administration of insulin:

Please indicate the time spent on activities related to the

administration of insulin, such as loading the syringes and

injecting the insulin or setting-up the insulin pump, where

applicable. (Do not include activities such as exercising,

traveling to or attending medical appointments, shopping for

medication, or recuperating after therapy).

Number of hours per week __________

Adjustment of insulin dosage:

Please indicate the time spent on activities that can reasonably

be considered necessary to adjust the dosage of insulin. For

example, glucose testing, calibration of the glucometer, ketones

testing, keeping a log of blood glucose results (excluding the

process of carbohydrate calculation).

Number of hours per week __________

Please specify which type of insulin administration applies to

your patient.

Insulin pump? Yes ______ No ______

Multiple daily injections? Yes ______ No ______

Please provide the year your patient started using an insulin

pump, if applicable. _____________________________________________

Please provide the year your patient started using multiple daily

insulin injections, if applicable. _______________________________

Is the impairment likely to improve sufficiently so that your

patient may no longer need life-sustaining therapy (e.g., with

surgery, organ transplant, or medication)?

Yes ______ No ______ Unsure ______

If Yes, please give the year you expect this change. _____________

__________________________________________________________________

Other comments: __________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

I certify that I have completed the above questionnaire.

Signature: __________________________________________________

It is a serious offence to make a

false statement

Date: ______________

Please return the ORIGINAL version of your completed questionnaire

in the enclosed envelope (or enclosed label) within 45 days of

receiving this letter. If you do not, we will have to close the

file since we will be unable to determine eligibility.

ANY MEDICAL FEES RELATED TO THIS CREDIT ARE THE RESPONSIBILITY OF

THE APPLICANT OR THE APPLICANT'S REPRESENTATIVE. HOWEVER, THE

APPLICANT CAN CLAIM THEM AS A MEDICAL EXPENSE (see line 330 in the

General Income Tax and Benefit Guide).

Yours sincerely,