Indicates required field

Musculoskeletal program of care provider registration

Clinic name

if applicable

Profession

First name

Please capitalize the first letter of your first name

Last name

Please capitalize the first letter of your last name

License

Address (street number, street name, suite/unit number)

City

Postal code

Phone number

Language

Enter all the languages you provide services in

Provider billing ID number (i.e., 100XXXXXX)

Provider statement:

I am a regulated health professional in good standing with my professional regulatory college
I confirm that I have the scope of practice, knowledge and skill to deliver the musculoskeletal program of care
I agree to participate in the mandatory education sessions on topics related to the musculoskeletal program of care
I have read and understand all the musculoskeletal program of care materials on the WSIB website
I agree to deliver care as described in the musculoskeletal program of care materials, in accordance with the recommended evidence-based interventions and agree to make sure the designated clinic area is safe, adequate in size and appropriate for delivering care
I understand the WSIB updates program materials from time to time and I will regularly visit the WSIB website to review any updates
I agree to complete the musculoskeletal program of care forms in accordance with submission timelines and submit these using the WSIB’s online services
I have a WSIB provider ID number
I will bill the WSIB for services performed in accordance with the musculoskeletal program of care fee schedule and guidelines
I will use the WSIB online services via TELUS Health to electronically bill for services performed
I agree to receive communication from the WSIB and TELUS Health through email or telephone and respond in a timely manner
I understand that the WSIB will conduct quality assurance activities and I agree to participate in meetings to discuss opportunities for continuous improvement
I agree to act in a respectful, courteous, and collaborative manner with people with work-related injuries or illnesses, the WSIB and other health professionals involved in the person’s care
I provide consent for the WSIB to list my professional contact information on their website in the musculoskeletal program of care directory, acknowledging that the WSIB is not responsible for any consequences resulting from the use by third parties of this information
I agree to contact the WSIB if any of my registration information or qualifications change

By checking this box, I am confirming and agreeing to the above provider statement. I understand that if I do not adhere to the above statement, it may result in my removal from delivering the musculoskeletal program of care and its directory.