Health care practitioner forms
Categories:
- Registration
- Reports
- Treatment extension requests
- Health information requests
- Other requests
- Program of care
- Order forms
|
Form Number |
Form Name |
|---|---|
| Registration | |
| 1890A (31.9kb, PDF) | Health Professional's Registration Application |
| Reports | |
| 0008A (281.2kb, PDF) |
Health Professional's Report (Form 8) We have revised the Health Professional’s Report (Form 8). The new form:
Read our Q and A about the new Form 8. |
|
(411k, pdf) |
Dental Report |
| 0856C (139.4kb, PDF)) |
Physiotherapy Assessment Report
|
| 0896A (58.7kb, PDF) | Health Professional's Progress Report (Form 26) View Only |
| 2234A (263k, pdf) | Health Professional Continuity Report (Form REO8) |
|
(125k, pdf) |
Regional Evaluation Centre Multidisciplinary Health Care Assessment Summary Report |
|
(24k, pdf) |
Regional Evaluation Centre Multidisciplinary Health Care Assessment Referral Form
|
|
(184k, pdf) |
ENT Consultation Report |
| 2647A (147.0kb, PDF) |
Please check your fee schedule for updated FAF fee. Read our Guide to Completing the Functional Abilities Form (239k, pdf) Old version (November 2000) of Functional Abilities Form for Timely Return to Work (187k, pdf, view only; Worker's Health number & Social Insurance number not required on form) |
| Treatment Extension Requests | |
|
(154k, pdf) |
Chiropractor's Treatment Extension Request |
|
(154k, pdf) |
Physiotherapist's Treatment Extension Request |
| Health Information Requests | |
|
(37k, jpg) |
Request for Hospital Medical Information |
|
(37k, jpg) |
Request for Hospital Medical Information: Occupational Disease View Only
|
|
(40k, jpg) |
Request for Health Information View Only |
| Other Requests | |
|
(405.2kb, PDF) |
Hearing Aid Special Needs Request |
|
(432.4kb, PDF) |
Hearing Aid Early Replacement |
|
(165k, pdf) |
Voluntary X-Ray & Pulmonary Function Test |
|
(245k, pdf) |
Notice of Temporary Assignment of Practice for Chiropractors |
|
(612k, pdf) |
Provider Payment Request |
| 3941A (83.0kb, PDF) | Provider Payment Request for Equipment/Supplies |
| Program of Care | |
|
(298k, pdf) |
Program of Care for Lower Extremity Injuries Initial Assessment Report |
|
(426k, pdf) |
Program of Care for Lower Extremity Injuries Care & Outcomes Summary Report |
|
(408k, pdf) |
Program of Care Occupational Asthma Screening & Initial Assessment Report |
|
(416k, pdf) |
Program of Care Occupational Asthma Care & Outcomes Summary Report |
|
(361k, pdf) |
Program of Care Occupational Asthma Reassessment Report |
|
(137k, pdf) |
Program of Care NIHL Rehabilitation Follow-Up Form |
|
(321k, pdf) |
Program of Care NIHL Assessment Summary and Treatment Plan Form |
|
(231k, pdf) |
Program of Care NIHL Trial Period Follow-Up Form |
|
(384k, pdf) |
Program of Care Occupational Contact Dermatitis Screening & Initial Assessment Report |
|
(308k, pdf) |
Program of Care Occupational Contact Dermatitis Reassessment Report |
|
(347k, pdf) |
Program of Care Occupational Contact Dermatitis Care & Outcomes Summary |
|
(267K, pdf) |
Program of Care for Upper Extremity Injuries Initial Assessment Report |
|
(353k, pdf) |
Program of Care for Upper Extremity Injuries Care and Outcomes Summary |
| 3238A (76.8kb, PDF) | Program of Care for Acute Low Back Injuries Initial Assessment Report |
| 3239A (37.6kb, PDF) | Program of Care for Acute Low Back Injuries Care and Outcomes Summary |
| 2522A (30.5kb, PDF) | Shoulder Program of Care Initial Assessment |
| 2524A (30.4kb, PDF) | Shoulder Program of Care Care and Outcomes Summary |
| Order Forms | |
|
(233k, pdf) |
Order Form for Health Professionals' Forms |
|
(228k, pdf) |
WSIB Policy Manuals/Newsletter Order Form |
