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Program of care provider registration

if applicable
Postal Code
Able to deliver Vestibular Rehabilitation
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Provider statement
  • I am a registered healthcare professional in autonomous practice and in good standing with my professional regulatory college
  • I have read the 2018 Ontario Neurotrauma Foundation Guidelines
  • I have completed the required webinar on the topic of the WSIB mTBI POC
  • I have read and understand all mTBI POC Materials on the WSIB website
  • I will deliver care as described in the mTBI POC Materials, including delivery of recommended interventions in keeping with the recommendations of the Ontario Neurotrauma Foundation Guidelines
  • I will regulary visit the WSIB website to review program materials as they may be revised and updated from time to time by WSIB
  • I agree to invoice according to the WSIB mTBI POC Fee Guidelines
  • I understand that the WSIB will conduct quality assurance activities
  • I have taken all steps necessary to obtain a WSIB Provider ID number (registering either as an individual health care professional or as a facility/clinic)
  • I will bill WSIB electronically for services (as applicable) performed as part of the WSIB mTBI POC
  • I provide consent for the WSIB to list my professional contact information on the online WSIB mTBI POC Network Directory, acknowledging that the WSIB is not responsible for any consequences resulting from the use by third parties of such information
  • I agree to receive communication from the WSIB/third party provider through email or telephone
  • I agree to contact WSIB should any of my registration information or qualifications change