Forms: Health care providers

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Categories:

• Report a patient's work-related physical injury or illness
• Update us on your patient's recovery and return to work
• Bill us for your services
• Treatment and programs
  • Programs of care
  • Non-surgical fracture episode of care
  • Community mental health program
• Request additional health information
• Request a hearing-related device
• Request treatment extension
• Order forms

Report a patient's work-related physical injury or illness

• Health professional's report – Form 8
   (0008A)
• Health professional's report for occupational mental stress (Form CMS8) (PDF 0010A)
• ENT consultation report (PDF 1787A)
• Dental report (PDF 0278A)
• Physiotherapy assessment report (PDF 0856C)

Update us on your patient's recovery and return to work

• Functional abilities form for early and safe return to work
  (2647A)
  • Guide to completing the functional abilities form (PDF)

Fee schedule for the updated FAF fee.

• Health professional's progress report (Form 26) view only
  (0896A)
• Health professional continuity report (Form REO8) (PDF 2234A)

For more information refer to the commonly used forms webpage.

Bill us for your services

Register and bill us easily through TELUS Health.

• Provider payment request (PDF) – 3947A)
• Provider payment request for equipment/supplies (PDF – 3941A)

Treatment and programs

Programs of care

• Instructions for delivering programs of care (PDF - 0916A)
• Musculoskeletal program of care: initial assessment report (PDF - 2345A)
• Musculoskeletal program of care: care and outcomes summary (discharge form) (PDF 2339A)
• Program of care NIHL hearing aid outcome report (PDF – 0037A2)
• Shoulder program of care initial assessment (PDF 2522A)
• Shoulder program of care – care and outcomes summary (PDF 2524A)
• Program of care for low back injuries: initial assessment report (PDF– 3238A)
• Program of care for low back injuries: care and outcomes summary (PDF - 3239A)
• Revised program of care for mild traumatic brain injuries Initial assessment report (PDF)
• Revised program of care for mild traumatic brain injuries Mid-point report (PDF)
• Revised program of care for mild traumatic brain injuries Care outcomes summary (PDF)
• Revised program of care mild traumatic brain injuries Supplementary report
   (when additional treatment is approved)

Non-surgical fracture episode of care

• Initial assessment report (PDF – 2610A)
• Summary report (PDF – 2611A)

Community mental health program

• Community Mental Health Program assessment form (PDF - 0201A)
• Community Mental Health Program Progress Form
  (0203A)
• Community mental health program RTW recommendations (PDF – 0204A)

Request additional health information

• Request for hospital medical information (PDF – 1801A)
• Request for hospital medical Information: occupational disease (PDF – 1823A view only)
• Request for health information  (PDF 2012A – view only)
• Notice of temporary assignment of practice for chiropractors (PDF - 1923A)

Request a hearing-related device

• Hearing assistive technologies (HAT) request form

  (10584A)

• Hearing aid replacement and/or clinical exception form

  (10585A)

Request a treatment extension

Note: Do not submit treatment extension requests for anyone being treated in a Program of Care or Episode of Care. Health care providers should call the Clinical Expert Line for case-specific clinical concerns. Read more in the Q&A document for the relevant Program of Care.

• Chiropractor's treatment extension request (PDF - 0148A)

• Physiotherapist's treatment extension request (PDF - 0153A)

Order forms

• Order form for health professionals' forms (PDF -1904C)