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Categories:
- Reports
- Treatment extension requests
- Health information requests
- Other requests
- Program of care
- Order forms
Form Number |
Form Name |
|---|---|
Reports |
|
| 0008A (PDF) |
Health Professional's Report (Form 8) This form should be used for work-related physical injuries and illnesses.For more information refer to the commonly used forms webpage. |
| CMS8 (PDF) | Health Professional’s Report for Occupational Mental Stress (Form CMS8) This new form should be used for work-related mental stress disorders or conditions. For more information, refer to the Form CMS8 frequently asked questions page or the commonly used forms webpage. |
|
0278A (PDF) |
Dental Report |
| 0856C (PDF) |
Physiotherapy Assessment Report |
| 0896A (PDF) | Health Professional's Progress Report (Form 26) View Only |
| 2234A (PDF) | Health Professional Continuity Report (Form REO8) |
|
1787A (PDF) |
ENT Consultation Report |
| 2647A (PDF) |
Please check your fee schedule for updated FAF fee. Read our Guide to Completing the Functional Abilities Form (PDF) |
| 0201A (PDF) | Community Mental Health Program Assessment Form |
| 0203A (PDF) | Community Mental Health Program Progress Form |
Treatment Extension Requests |
|
|
Note: Do not submit treatment extension requests forms for workers who are currently being treated under the Programs of Care or Episode of Care. Health Care Providers should call the Clinical Expert Line to discuss case specific clinical concerns. For further information, please refer to the Q&A documents available under the Programs of Care. |
|
|
0148A (PDF) |
Chiropractor's Treatment Extension Request |
|
0153A (PDF) |
Physiotherapist's Treatment Extension Request |
| Health Information Requests | |
|
1801A (PDF) |
Request for Hospital Medical Information |
|
1823A (PDF) |
Request for Hospital Medical Information: Occupational Disease View Only |
|
2012A (PDF) |
Request for Health Information View Only |
Other Requests |
|
|
2869A (PDF) |
Hearing Aid Special Needs Request |
|
2889A (PDF) |
Hearing Aid Early Replacement |
|
1923A (PDF) |
Notice of Temporary Assignment of Practice for Chiropractors |
|
3947A (PDF) |
Provider Payment Request |
| 3941A (PDF) | Provider Payment Request for Equipment/Supplies |
Program of Care |
|
| 0916A (PDF) | Instructions for Delivering Programs of Care |
| 2345A (PDF) | Musculoskeletal Program of Care: Initial Assessment Report |
| 2339A (PDF) | Musculoskeletal Program of Care: Care and Outcomes Summary (discharge form) |
|
0037A2 (PDF) |
Program of Care NIHL Hearing Aid Outcome Report |
| 2522A (PDF) | Shoulder Program of Care Initial Assessment |
| 2524A (PDF) | Shoulder Program of Care Care and Outcomes Summary |
| 3238A (PDF) | Program of Care for Low Back Injuries Initial Assessment Report |
| 3239A (PDF) | Program of Care for Low Back Injuries Care and Outcomes Summary |
| 3240A (PDF) | Program of Care for Mild Traumatic Brain Injuries Initial Assessment Report |
| 3241A (PDF) | Program of Care for Mild Traumatic Brain Injuries Care and Outcomes Summary |
Non-Surgical Fracture Episode of Care |
|
| 2610A (PDF) | Initial Assessment Report |
| 2611A (PDF) | Summary Report |
Order Forms |
|
| 1904C (PDF) | Order Form for Health Professionals' Forms |