Disability Benefits Assistance Referral Form

cid

EVRR ID

Section One: Information of the person being referred

Person's Health Card Number

First Name

Last Name

Person's Date Of Birth

Gender

Person's Telephone Number (day time or cell)

Street

City

Province

Postal Code

Country

Person's preferred language

If Other language, please specify

Section Two: Supplemental personal information

VLRC office closest to the patient

Do you (the person being referred) identify as an Indigenous person, such as First Nation, Inuk (Inuit), or Métis?

If yes, please select from the following.
If number is not known please type “Number not known” in the appropriate text box:

This is a multi select - Use Control + Select to choose multiple options

Inuit-Government of Nunavut Health Plan Number

Inuk/Inuit-NIHB (N Number)

Inuk/Inuit-North West Territories Health Plan Number

First Nations-Indian Act Registration number

First Nations-NIHB ID (B Number)

Métis-Indian Act Registration number

Métis Sponsorship-Band#+Family#

Are you (or the person being referred) a current, former or retired member of the Canadian Armed Forces or the Royal Canadian Mounted Police (RCMP)?

If yes, can you provide a K-number?

If yes, please provide K-number?

Are you currently or have previously received services from Vision Loss Rehabilitation Canada?

As described in more detail in the next section this form is specifically to access assistance for Federal, Provincial and Territorial programs for people with disabilities, however if you do have vision loss, are you interested in VLRC’s other services specific to people with vision loss?

Due to your vision loss, have you (the person being referred) fallen within the last 3 months?

Due to your vision loss, have you (the person being referred) burned yourself?

Due to your vision loss, are you (the person being referred) at risk of losing your job?

Due to your vision loss, are you (the person being referred) at risk of academic failure?

Due to your vision loss, have you (the person being referred) taken the wrong medication?

Are there any disability related accommodations we can provide? If yes, please include them below.

Section Three: Reason(s) for referral

Are you looking for information about the Disability Tax Credit (DTC), the Canada Disability Benefit (CDB) or other federal, provincial or territorial benefits?

Would you like assistance in applying for a tax benefit or credit?

Are you seeking assistance with an appeal?

Is there anything else you would like to share with us?

Section Four: Consent

If you are referring yourself, do you consent to releasing your information to VLRC?

If you are referring someone, are they aware of this referral and have they provided their consent to release their information to VLRC?

Section Five: Referring agency information

Referral completed by

Name of person making referral

Organization/Relationship

Relationship

Phone number

Contact Information