*** Transcriber's Note: Please set your voice synthesizer to read most punctuation. When you encounter the caret sign at the end of a line, please enter the applicable information, if necessary. *** Canada Revenue Agency Protected B when completed T2201 E (23) (Page 1 of 16) Disability Tax Credit Certificate Help canada.ca/disability-tax-credit 1-800-959-8281 The information provided in this form will be used by the Canada Revenue Agency (CRA) to determine the eligibility of the individual applying for the disability tax credit (DTC). For more information, see the general information on page 16. Part A - Individual's section 1) Tell us about the person with the disability First name: ^ Last name: ^ Social insurance number (enter 9 digits): ^ Mailing address: ^ City: ^ Province or territory: ^ Postal code: ^ Date of birth (Year/Month/Day): ^ 2) Tell us about the person intending to claim the disability amount (if different from above) This person must be a supporting family member of the person with the disability (the spouse or common-law partner of the person with the disability, or a parent, grandparent, child, grandchild, brother, sister, uncle, aunt, nephew, or niece of that person or their spouse or common-law partner). First name: ^ Last name: ^ Relationship: ^ Social insurance number (enter 9 digits): ^ Does the person with the disability live with you? Yes or No ^ Indicate which of the basic necessities of life have been regularly and consistently provided to the person with the disability, and the years for which it was provided: Food ^ Year(s) ^ Shelter ^ Year(s) ^ Clothing ^ Year(s) ^ Provide details regarding the support you provide to the person with the disability (regularity of the support, proof of dependency, if the person lives with you, etc.): ^ If you and another person support the same dependant, you may split the claim for that dependant. However, the total amount of your claim and the other person's claim cannot be more than the maximum amount allowed for that dependant. If you want to provide more information than the space allows, or another supporting family member would like to add information about the support they provide, use a separate sheet of paper, sign it, and attach it to this form. Make sure to provide all identifying information, including social insurance numbers and signatures from all supporting family members. As the supporting family member intending to claim the disability amount, I confirm the above information is accurate. This authorization will not result in automatic adjustments to my previous tax returns. Signature: ^ T2201 E (23) (Page 2 of 16) Part A - Individual's section (continued) 3) Previous tax return adjustments Are you the person with the disability or their legal representative (or if the person is under 18, their legal guardian)? Yes or No ^ Note: If no, or more than one person is claiming the disability amount, you will need to send a Form T1-ADJ for each year to be adjusted or a letter with the details of your request(s). If eligibility for the disability tax credit is approved, would you like the CRA to apply the credit to your previous tax returns? Yes, adjust my previous tax returns for all applicable years. ^ No, do not adjust my previous tax returns at this time. ^ 4) Individual's authorization (mandatory) As the person with the disability or their legal representative: - I certify that the above information is correct. - I give permission for my medical practitioner(s) to provide the CRA with information from their medical records in order for the CRA to determine my eligibility. - I authorize the CRA to adjust my returns, as applicable, if I opted to do so in question 3. Signature: ^ If this form is not signed by the person with the disability or their legal representative (or if the person is under 18, their legal guardian), the CRA will not process this form. Telephone number (including area code): ^ Date (Year/Month/Day): ^ Personal information (including the SIN) is collected and used to administer or enforce the Income Tax Act and related programs and activities including administering tax, benefits, audit, compliance, and collection. The information collected may be disclosed to other federal, provincial, territorial, aboriginal, or foreign government institutions to the extent authorized by law. Failure to provide this information may result in paying interest or penalties, or in other actions. Under the Privacy Act, individuals have a right of protection, access to and correction of their personal information, or to file a complaint with the Privacy Commissioner of Canada regarding the handling of their personal information. Refer to Personal Information Bank CRA PPU 218 on Info Source at canada.ca/cra-info- source. This marks the end of the individual's section of the form. Ask a medical practitioner to fill out Part B (pages 3-16). Once the medical practitioner certifies the form, it is ready to be submitted to the CRA for assessment. Next steps: Step 1 - Ask your medical practitioner(s) to fill out the remaining pages of this form. Note Your medical practitioner provides the CRA with your medical information but does not determine your eligibility for the DTC. Step 2 - Make a copy of the filled out form for your own records. Step 3 - Refer to page 16 for instructions on how to submit your form to the CRA. T2201 E (23) (Page 3 of 16) Part B - Medical practitioner's section If you would like to use the digital application for medical practitioners to fill out your section of the T2201, it can be found at canada.ca/dtc-digital- application. Important notes on patient eligibility - Eligibility for the DTC is not based solely on the presence of a medical condition. It is based on the impairment resulting from a condition and the effects of that impairment on the patient. Eligibility, however, is not based on the patient's ability to work, to do housekeeping activities, or to engage in recreational activities. - A person may be eligible for the DTC if they have a severe and prolonged impairment in physical or mental functions resulting in a marked restriction. A marked restriction means that, even with appropriate therapy, devices, and medication, they are unable or take an inordinate amount of time in one impairment category, all or substantially all(generally interpreted as 90% or more) of the time. If their limitations do not meet the criteria for one impairment category alone, they may still be eligible if they experience significant limitations in two or more categories. For more information about the DTC, including examples and eligibility criteria, see Guide RC4064, Disability-Related Information, or go to canada.ca/disability-tax-credit. Next steps Step 1 - Fill out the sections of the form on pages 4-15 that are applicable to your patient. When considering your patient's limitations, assess them compared to someone of similar age who does not have an impairment in that particular category. If your patient experiences limitations in more than one category, they may be eligible under the "Cumulative effect of significant limitations" section on page 14. If you want to provide more information than the space allows, use a separate sheet of paper, sign it, and attach it to this form. Make sure to include the name of the patient at the top of all pages. Step 2 - Fill out the "Certification" section on page 16 and sign the form. Step 3 - You or your patient can send this form to the CRA when both Part A and Part B are filled out and signed (refer to page 16 for instructions). The CRA will review the information provided to determine your patient's eligibility and advise your patient of its decision. If more information is needed, the CRA may contact you. Personal information (including the SIN) is collected and used to administer or enforce the Income Tax Act and related programs and activities including administering tax, benefits, audit, compliance, and collection. The information collected may be disclosed to other federal, provincial, territorial, aboriginal or foreign government institutions to the extent authorized by law. Failure to provide this information may result in paying interest or penalties, or in other actions. Under the Privacy Act, individuals have a right of protection, access to and correction of their personal information, or to file a complaint with the Privacy Commissioner of Canada regarding the handling of their personal information. Refer to Personal Information Bank CRA PPU 218 on Info Source at canada.ca/cra-info- source. T2201 E (23) (Page 4 of 16) Patient's name: ^ If your patient has an impairment in vision, initial your professional designation and complete this section. Medical doctor ^ Nurse practitioner ^ Optometrist ^ Vision 1) List any medical conditions or diagnoses that impair your patient's ability to see, and provide the year of diagnosis (if available): ^ 2) Indicate the aspect of vision that is impaired in each eye (visual acuity, field of vision, or both): Left eye after correction Visual acuity Measurable on the Snellen chart (provide acuity) ^ Example: 20/200, 6/60 ^ Count fingers (CF) ^ No light perception (NLP) ^ Light perception (LP) ^ Hand motion (HM) ^ Field of vision(provide greatest diameter) degrees ^ Right eye after correction Visual acuity Measurable on the Snellen chart (provide acuity) ^ Example: 20/200, 6/60 ^ Count fingers (CF) ^ No light perception (NLP) ^ Light perception (LP) ^ Hand motion (HM) ^ Field of vision (provide greatest diameter) degrees ^ 3) Does your patient meet at least one of the following criteria in both eyes, even with the use of corrective lenses or medication? - The visual acuity is 20/200 (6/60) or less on the Snellen Chart (or an equivalent). - The greatest diameter of the field of vision is 20 degrees or less. Yes or No (Note 1) ^ Note 1: If you answered no and your patient is impaired in two or more categories, they may be eligible under the "Cumulative effect of significant limitations" on page 14. 4) Provide the year that your patient became impaired based on your previous answers: Year ^ 5) Has your patient's impairment in vision lasted, or is it expected to last, for a continuous period of at least 12 months? Yes or No ^ 6) Has your patient's impairment in vision improved or is it likely to improve to such an extent that they would no longer be impaired? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 5 of 16) Patient's name: ^ If your patient has an impairment in speaking, initial your professional designation and complete this section. Medical doctor ^ Nurse practitioner ^ Speech-language pathologist ^ Speaking 1) List any medical conditions or diagnoses that impair your patient's ability to speak, so as to be understood by a familiar person in a quiet setting, and provide the year of the diagnosis (if available): ^ 2) Does your patient take medication to help manage their impairment in speaking? Yes, No or Unsure ^ 3) Describe if your patient uses any devices or therapy to help manage their impairment in speaking (for example, voice amplifier, behaviour therapy). ^ 4) Provide examples that describe how your patient's ability to speak - so as to be understood by a familiar person in a quiet setting – is impaired even with appropriate therapy, medication, and devices - this is mandatory. For example, they require repetition to be understood, have difficulty with articulation, require more time for word retrieval or to respond to verbal information, experience mutism, or use sign language as their primary means of communicating. ^ 5) Is your patient unable to speak, or do they take an inordinate amount of time to speak so as to be understood (at least three times longer than someone of similar age without an impairment in speaking) by a familiar person in a quiet setting, even with the use of appropriate therapy, medication, and devices? Yes or No (Note 1) ^ Note 1: If you answered no and your patient is impaired in two or more categories, they may be eligible under the "Cumulative effect of significant limitations" on page 14. 6) Is this the case all or substantially all of the time (see page 3)? Yes or No ^ 7) Provide the year when your patient became impaired based on your previous answers: Year ^ 8) Has your patient's impairment in speaking lasted, or is it expected to last, for a continuous period of at least 12 months? Yes or No ^ 9) Has your patient's impairment in speaking improved or is it likely to improve to such an extent that they would no longer be impaired? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 6 of 16) Patient's name: ^ If your patient has an impairment in hearing, initial your professional designation and complete this section. Medical doctor ^ Nurse practitioner ^ Audiologist ^ Hearing 1) List any medical conditions or diagnoses that impair your patient's ability to hear so as to understand a familiar person in a quiet setting, and provide the year of the diagnosis (if available): ^ 2) Indicate the level that best describes your patient's hearing loss in each ear (normal: 0-25dB, mild: 26-40dB, moderate: 41-55dB, moderate-to-severe: 56-70dB, severe: 71-90dB, profound: 91dB+, or unknown): Left ear ^ Right ear ^ 3) Describe if your patient uses any devices or therapy to help manage their impairment in hearing (for example, cochlear implant, hearing aid): ^ 4) Provide examples that describe how your patient's ability to hear a familiar person in a quiet setting is impaired despite the use of appropriate therapy, medication, and devices - this is mandatory. For example, they require repetition when listening to others, have poor word discrimination, or need to use lip-reading or sign-language to understand verbal communication. ^ 5) Is your patient unable to hear, or do they take an inordinate amount of time to hear so as to understand (at least three times longer than someone of similar age without an impairment in hearing) a familiar person in a quiet setting, even with the use of appropriate therapy, medication, and devices? Yes or No (Note 1) ^ Note 1: If you answered no and your patient is impaired in two or more categories, they may be eligible under the "Cumulative effect of significant limitations" on page 14. 6) Is this the case all or substantially all of the time (see page 3)? Yes or No ^ 7) Provide the year when your patient became impaired based on your previous answers: Year ^ 8) Has your patient's impairment in hearing lasted, or is it expected to last, for a continuous period of at least 12 months? Yes or No ^ 9) Has your patient's impairment in hearing improved or is it likely to improve to such an extent that they would no longer be impaired? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 7 of 16) Patient's name: ^ If your patient has an impairment in walking, initial your professional designation and complete this section. Medical doctor ^ Nurse practitioner ^ Occupational therapist ^ Physiotherapist ^ Walking 1) List any medical conditions or diagnoses that impair your patient's ability to walk, and provide the year of the diagnosis (if available): ^ 2) Does your patient take medication to help manage their impairment in walking? Yes, No or Unsure ^ 3) Describe if your patient uses any devices or therapy to help manage their impairment in walking (for example: cane, occupational therapy): ^ 4) Provide examples that describe how your patient's ability to walk (for example, a short distance such as 100 metres) is impaired despite the use of appropriate therapy, medication, and devices - this is mandatory. For example, they need assistance when they walk, they have impaired balance, or as a result of pain or shortness of breath they require frequent breaks when walking. ^ 5) Is your patient unable to walk, or do they take an inordinate amount of time to walk (at least three times longer than someone of similar age without an impairment in walking), for example a short distance such as 100 metres, even with appropriate therapy, medication and devices? Yes or No (Note 1) ^ Note 1: If you answered no and your patient is impaired in two or more categories, they may be eligible under the "Cumulative effect of significant limitations" on page 14. 6) Is this the case all or substantially all of the time (see page 3)? Yes or No ^ 7) Provide the year when your patient became impaired based on your previous answers: Year ^ 8) Has your patient's impairment in walking lasted, or is it expected to last, for a continuous period of at least 12 months? Yes or No ^ 9) Has your patient's impairment in walking improved or is it likely to improve to such an extent that they would no longer be impaired? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 8 of 16) Patient's name: ^ If your patient has an impairment in eliminating, initial your professional designation and complete this section. Medical doctor ^ Nurse practitioner ^ Eliminating 1) List any medical conditions or diagnoses that impair your patient's ability to personally manage bowel or bladder functions, and provide the year of the diagnosis (if available): ^ 2) Does your patient take medication to help manage their impairment in bowel or bladder functions? Yes, No or Unsure ^ 3) Describe if your patient uses any devices or therapy to help manage their impairment in bowel or bladder functions (for example, ostomy, biological therapy): ^ 4) Provide examples that describe how your patient's ability to personally manage bowel or bladder functions is impaired, despite the use of appropriate therapy, medication, and devices - this is mandatory. For example, they require assistance from another person, they rely on enemas due to chronic constipation, they wear incontinence briefs to manage fecal or urinary incontinence, or they require intermittent catheterization. ^ 5) Is your patient unable to personally manage bowel or bladder functions, or do they take an inordinate amount of time to personally manage bowel or bladder functions (at least three times longer than someone of similar age without an impairment in eliminating), even with appropriate therapy, medication, and devices? Yes or No (Note 1) ^ Note 1: If you answered no and your patient is impaired in two or more categories, they may be eligible under the "Cumulative effect of significant limitations" on page 14. 6) Is this the case all or substantially all of the time (see page 3)? Yes or No ^ 7) Provide the year when your patient became impaired based on your previous answers: Year ^ 8) Has your patient's impairment in bowel or bladder functions lasted, or is it expected to last, for a continuous period of at least 12 months? Yes or No ^ 9) Has your patient's impairment in bowel or bladder functions improved or is it likely to improve to such an extent that they would no longer be impaired? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 9 of 16) Patient's name: ^ If your patient has an impairment in feeding, initial your professional designation and complete this section. Medical doctor ^ Nurse practitioner ^ Occupational therapist ^ Feeding 1) List any medical conditions or diagnoses that impair your patient's ability to feed themselves, and provide the year of the diagnosis (if available): ^ 2) Does your patient take medication to help manage their impairment in feeding themselves? Yes, No or Unsure ^ 3) Describe if your patient uses any devices or therapy to help manage their impairment in feeding themselves (for example, assistive utensils, occupational therapy): ^ 4) Provide examples that describe how your patient's ability to feed themselves is impaired, despite the use of appropriate therapy, medication, and devices - this is mandatory. Feeding oneself includes preparing food (except when the time spent preparing food is related to a dietary restriction or regime). It does not include identifying, finding, shopping for, or obtaining food. For example, they cannot hold utensils, they rely exclusively on tube feeding, or they require assistance from someone else to prepare their meals or feed themselves. ^ 5) Is your patient unable to feed themselves, or do they take an inordinate amount of time to feed themselves (at least three times longer than someone of similar age without an impairment in feeding), even with the use of appropriate therapy, medication and devices? Yes or No (Note 1) ^ Note 1: If you answered no, and your patient is impaired in two or more categories, they may be eligible under the "Cumulative effect of significant limitations" on page 14. 6) Is this the case all or substantially all of the time (see page 3)? Yes or No ^ 7) Provide the year when your patient became impaired based on your previous answers: Year ^ 8) Has your patient's impairment in feeding themselves lasted, or is it expected to last, for a continuous period of at least 12 months? Yes or No ^ 9) Has your patient's impairment in feeding themselves improved or is it likely to improve to such an extent that they would no longer be impaired? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 10 of 16) Patient's name: ^ If your patient has an impairment in dressing, initial your professional designation and complete this section. Medical doctor ^ Nurse practitioner ^ Occupational therapist ^ Dressing 1) List any medical conditions or diagnoses that impair your patient's ability to dress themselves, and provide the year of the diagnosis (if available): ^ 2) Does your patient take medication to help manage their impairment in dressing? Yes, No or Unsure ^ 3) Describe if your patient uses any devices or therapy to help manage their impairment in dressing themselves (for example, button hook, occupational therapy): ^ 4) Provide examples that describe how your patient's ability to dress themselves is impaired, despite the use of appropriate therapy, medication, and devices - this is mandatory. Dressing oneself does not include identifying, shopping for, or obtaining clothing. For example, they experience pain in their upper extremities, they have a limited range of motion, or they require assistance from someone else to dress themselves. ^ 5) Is your patient unable to dress themselves, or do they take an inordinate amount of time to dress themselves (at least three times longer than someone of similar age without an impairment in dressing), even with the use of appropriate therapy, medication and devices? Yes or No (Note 1) ^ Note 1: If you answered no, and your patient is impaired in two or more categories, they may be eligible under the "Cumulative effect of significant limitations" on page 14. 6) Is this the case all or substantially all of the time (see page 3)? Yes or No ^ 7) Provide the year when your patient became impaired based on your previous answers: Year ^ 8) Has your patient's impairment in dressing themselves lasted, or is it expected to last, for a continuous period of at least12 months? Yes or No ^ 9) Has your patient's impairment in dressing themselves improved or is it likely to improve to such an extent that they would no longer be impaired? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 11 of 16) Patient's name: ^ If your patient has an impairment in mental functions necessary for everyday life, initial your professional designation and complete this section. Medical doctor ^ Nurse practitioner ^ Psychologist ^ Mental functions necessary for everyday life Mental functions necessary for everyday life include adaptive functioning, attention, concentration, goal-setting, judgment, memory, perception of reality, problem-solving, regulation of behaviour and emotions, and verbal and non-verbal comprehension. 1) List any medical conditions or diagnoses that impair your patient's ability to perform mental functions necessary for everyday life, and provide the year of diagnosis (if available): ^ 2) Does your patient take medication to help manage their impairment in mental functions necessary for everyday life? Yes, No or Unsure ^ Does your patient require supervision or reminders from another person to take their medication? This question is not applicable to children. Yes, No or Unsure ^ Select the option that best describes how effectively the medication helps manage their impairment in mental functions necessary for everyday life: Effective ^ Moderately effective ^ Mildly effective ^ Ineffective ^ Unsure ^ 3) Describe any devices or therapy your patient uses to help manage their impairment in mental functions necessary for everyday life (for example, memory aids, assistive technology, cognitive-behavioural therapy): ^ 4) Does your patient have an impaired capacity to live independently (or to function at home or at school in the case of a child under 18) without daily supervision or support from others? No or Yes ^ Select all types of support received by the adult or child under 18: Adult Assisted living or long-term facility ^ Community-based health services ^ Hospitalization ^ Support from family members ^ Child under 18 Adult supervision at home beyond an age-appropriate level ^ Additional support from educational staff at school ^ Provide additional details about support received (optional): ^ The Mental functions section continues on pages 12 and 13. T2201 E (23) (Page 12 of 16) Patient's name: ^ Mental functions necessary for everyday life (continued) 5) Select the box that best describes the extent of your patient's impairment, if any, for each of the mental functions listed below, compared to someone of similar age without an impairment in mental functions necessary for everyday life. Note: For a child, you can indicate either their current or anticipated impairment. Adaptive functioning Adapt to change No limitations ^ Some limitations ^ Severe limitations ^ Express basic needs No limitations ^ Some limitations ^ Severe limitations ^ Go out into the community No limitations ^ Some limitations ^ Severe limitations ^ Initiate common, simple transactions No limitations ^ Some limitations ^ Severe limitations ^ Perform basic hygiene or self-care activities No limitations ^ Some limitations ^ Severe limitations ^ Perform necessary, everyday tasks No limitations ^ Some limitations ^ Severe limitations ^ Attention Demonstrate awareness of danger and risks to personal safety No limitations ^ Some limitations ^ Severe limitations ^ Demonstrate basic impulse control No limitations ^ Some limitations ^ Severe limitations ^ Concentration Focus on a simple task for any length of time No limitations ^ Some limitations ^ Severe limitations ^ Absorb and retrieve information in the short-term No limitations ^ Some limitations ^ Severe limitations ^ Goal-setting Make and carry out simple day-to-day plans No limitations ^ Some limitations ^ Severe limitations ^ Self-direct to begin everyday tasks No limitations ^ Some limitations ^ Severe limitations ^ Judgment Choose weather-appropriate clothing No limitations ^ Some limitations ^ Severe limitations ^ Make decisions about their own treatment and welfare No limitations ^ Some limitations ^ Severe limitations ^ Recognize risk of being taken advantage of by others No limitations ^ Some limitations ^ Severe limitations ^ Understand consequences of their actions or decisions No limitations ^ Some limitations ^ Severe limitations ^ Memory Remember basic personal information such as date of birth and address No limitations ^ Some limitations ^ Severe limitations ^ Remember material of importance and interest to themselves No limitations ^ Some limitations ^ Severe limitations ^ Remember simple instructions No limitations ^ Some limitations ^ Severe limitations ^ Perception of reality Demonstrate an accurate understanding of reality No limitations ^ Some limitations ^ Severe limitations ^ Distinguish reality from delusions and hallucinations No limitations ^ Some limitations ^ Severe limitations ^ Problem-solving Identify everyday problems No limitations ^ Some limitations ^ Severe limitations ^ Implement solutions to simple problems No limitations ^ Some limitations ^ Severe limitations ^ Regulation of behaviour and emotions Behave appropriately for the situation No limitations ^ Some limitations ^ Severe limitations ^ Demonstrate appropriate emotional responses for the situation No limitations ^ Some limitations ^ Severe limitations ^ Regulate mood to prevent risk of harm to self or others No limitations ^ Some limitations ^ Severe limitations ^ Verbal and non-verbal comprehension Understand and respond to non-verbal information or cues No limitations ^ Some limitations ^ Severe limitations ^ Understand and respond to verbal information No limitations ^ Some limitations ^ Severe limitations ^ The Mental functions section continues on page 13. T2201 E (23) (Page 13 of 16) Patient's name: ^ Mental functions necessary for everyday life (continued) Mental functions necessary for everyday life include adaptive functioning, attention, concentration, goal-setting, judgment, memory, perception of reality, problem-solving, regulation of behaviour and emotions, and verbal and non-verbal comprehension. 6) Provide examples that describe your patient's impairment if you indicated they have "some limitations" on page 12, or if you have additional examples related to your patient's ability to perform mental functions necessary for everyday life. ^ 7) Is your patient unable to, or do they take an inordinate amount of time to perform mental functions necessary for everyday life (at least three times longer than someone of similar age without an impairment in mental functions), even with the use of appropriate therapy, medication and devices? Yes or No (Note 1) ^ Note 1: If you answered no, and your patient is impaired in two or more categories, they may be eligible under the "Cumulative effect of significant limitations" on page 14. 8) Is this the case all or substantially all of the time (see page 3)? Yes or No ^ 9) Provide the year when your patient became impaired based on your previous answers: Year ^ 10) Has your patient's impairment in performing mental functions necessary for everyday life lasted, or is it expected to last, for a continuous period of at least 12 months? Yes or No ^ 11) Has your patient's impairment in performing mental functions necessary for everyday life improved or is it likely to improve to such an extent that they would no longer be impaired? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 14 of 16) Patient's name: ^ If your patient is impaired in two or more categories, initial your professional designation and complete this section. Medical doctor ^ Nurse practitioner ^ Occupational therapist (Note 2) ^ Note 2: An occupational therapist can only certify limitations for walking, feeding, and dressing. Cumulative effect of significant limitations When a person is impaired in two or more categories, they may be eligible under "cumulative effect of significant limitations" if the combined effect of their significant limitations is equivalent to a marked restriction (see page 3). 1) Select all categories in which your patient has significant limitations, even with appropriate therapy, medication, and devices: Vision ^ Hearing ^ Eliminating (bowel or bladder functions) ^ Dressing ^ Speaking ^ Walking ^ Feeding ^ Mental functions necessary for everyday life ^ 2) Provide examples that describe your patient's significant limitations in the categories of impairment you selected above, despite the use of appropriate therapy, medication, and devices - this is mandatory. ^ 3) Do your patient's limitations in at least two of the categories selected above exist together all or substantially all of the time (see page 3)? Note: Although a person may not engage in the activities simultaneously, "together" in this context means that they are affected by the significant limitations during the same period of time. Yes or No ^ 4) Is the cumulative effect of these limitations equivalent to being unable or taking an inordinate amount of time in one single category of impairment, all or substantially all of the time (see page 3)? Yes or No ^ 5) Provide the year the cumulative effect of the limitations described above began: Year ^ 6) Have your patient's impairments in two or more of the categories selected lasted, or are they expected to last, for a continuous period of at least 12 months? Yes or No ^ 7) Have your patient's impairments improved, or are they expected to improve to such an extent that your patient would no longer be impaired in at least two of the categories selected? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 15 of 16) Patient's name: ^ Initial your professional designation if this category is applicable to your patient: Medical doctor ^ Nurse practitioner ^ Life-sustaining therapy Life-sustaining therapy - for type 1 diabetes (2021 and later years) People with type 1 diabetes are deemed to meet the eligibility criteria under life-sustaining therapy for 2021 and later years. 1) Indicate when your patient was diagnosed with type 1 diabetes: Prior to 2021 - continue to question 2 ^ 2021 and later - provide the year and skip to the Certification section: 202^ Life-sustaining therapy - for all conditions & therapies Eligibility criteria for life-sustaining therapy are as follows: - The therapy supports a vital function. - The therapy is needed at least 2 times per week(3 times a week for years prior to 2021). - The therapy is needed for an average of at least14 hours per week including only the time that your patient or another person must dedicate to the therapy. This means that the time they spend on activities to administer the therapy requires them to take time away from normal everyday activities. The following table includes some examples of eligible and ineligible activities: Eligible activities that count towards the 14 hours per week: - Activities directly related to adjusting and administering dosage of medication or determining the amount of a compound that can be safely consumed - Maintaining a log related to the therapy - Managing dietary restrictions or regimes related to therapy requiring daily consumption of a medical food or formula to limit intake of a particular compound or requiring a regular dosage of medication that needs to be adjusted on a daily basis - Receiving life-sustaining therapy at home or at an appointment - Setting up and maintaining equipment used for the therapy Ineligible activities that do not count towards the 14 hours per week: - Exercising - Managing dietary restrictions or regimes other than in the situations described in the eligible activities - Medical appointments that do not involve receiving the therapy or determining the daily dosage of medication, medical food, or medical formula - Obtaining medication - Recuperation after therapy (unless medically required) - Time a portable or implanted device takes to deliver therapy - Travel to receive therapy 2) Indicate your patient's life-sustaining therapy and medical conditions: Life-sustaining therapy: Multiple daily insulin injections ^ Insulin pump ^ Hemodialysis ^ Peritoneal dialysis ^ Intermittent oxygen therapy ^ 24-hour oxygen therapy ^ Tube feeding ^ Chest physiotherapy ^ Other (specify) ^ Medical conditions: Type 1 diabetes ^ Type 2 diabetes ^ End-stage renal disease ^ Phenylketonuria (PKU) ^ Cystic fibrosis ^ Other (specify) ^ 3) List the eligible activities for which your patient or another person dedicates time to administer the life-sustaining therapy (see above reference list): ^ 4) Does your patient need the therapy to support a vital function? Yes or No ^ 5) Provide the minimum number of times per week your patient needs to receive the life-sustaining therapy: times per week ^ 6) Provide the average number of hours per week your patient or another person needs to dedicate to activities in order to administer the life- sustaining therapy: hours per week ^ 7) Provide the year your patient began to need life-sustaining therapy as per your previous answers above: Year ^ 8) Has the impairment that necessitated the life-sustaining therapy lasted, or is it expected to last, for a continuous period of at least 12 months? Yes or No ^ 9) Has your patient's impairment that required the life-sustaining therapy improved, or is it likely to improve to such an extent that your patient would no longer be in need of the life-sustaining therapy? Yes (provide year) ^ Year ^ No ^ Unsure ^ T2201 E (23) (Page 16 of 16) Patient's name: ^ Certification (mandatory) 1) For which year(s) has the person with the disability been your patient? ^ to ^ 2) Do you have medical information on file for all the year(s) you certified on this form? Yes or No ^ Select the medical practitioner type that applies to you. Tick one box only: Medical doctor ^ Nurse practitioner ^ Optometrist ^ Occupational therapist ^ Audiologist ^ Physiotherapist ^ Psychologist ^ Speech-language pathologist ^ As a medical practitioner, I certify that this information is correct to the best of my knowledge. I understand that this information will be used by the CRA to make a decision if my patient is eligible for the DTC. Signature: (It is a serious offence to make a false statement.) ^ Name (print): ^ Medical license or registration number (optional): ^ Telephone number (including area code): ^ Date (Year/Month/Day): ^ Address: ^ General information Disability tax credit The disability tax credit (DTC) is a non-refundable tax credit that helps persons with disabilities or their supporting persons reduce the amount of income tax they may have to pay. For more information, go to canada.ca/disability-tax-creditor see Guide RC4064, Disability-Related Information. Eligibility A person with a severe and prolonged impairment in physical or mental functions may be eligible for the DTC. To find out if you may be eligible for the DTC, fill out the self-assessment questionnaire in Guide RC4064, Disability-Related Information. After you send the form Make sure to keep a copy of your application for your records. After we receive your application, we will review it and make a decision based on the information provided by your medical practitioner. We will then send you a notice of determination to inform you of our decision. You are responsible for any fees that the medical practitioner charges to fill out this form or to give us more information. You may be able to claim these fees as medical expenses on line 33099 or line 33199 of your income tax and benefit return. If you have questions or need help If you need more information after reading this form, go to canada.ca/disability-tax-creditor call 1-800-959-8281. Forms and publications To get our forms and publications, go to canada.ca/cra-forms or call1-800- 959-8281. How to send in your form You can send your completed form at any time during the year online or by mail. Sending your form before you file your annual income tax and benefit return may help us assess your return faster. Online Submitting your form online is secure and efficient. You will get immediate confirmation that it has been received by the CRA. To submit online, scan your form and send it through the "Submit documents" service in My Account at canada.ca/my-cra-account. If you're a representative, you can access this service in Represent a Client at canada.ca/taxes-representatives. By Mail You can send your application to the tax centre closest to you: Winnipeg Tax Centre Post Office Box 14000, Station Main Winnipeg MB R3C 3M2 Sudbury Tax Centre Post Office Box 20000, Station A Sudbury ON P3A 5C1 Jonquière Tax Centre 2251 René-Lévesque Boulevard Jonquière QC G7S 5J2 For internal use ^