Ontario Accident Benefits

Claim Number:*

Referral Source

Name:*

Email:*

Title:

Company:*

Phone:*

Ext:

Fax:*

Address:*

City:*

Province:*

Postal Code:*

Principle Insurer:

Claimant Information

Salutation:

First Name:*

Last Name:*

Address:*

City:*

Province:*

Postal Code:*

Home Phone:*

Other Phone:

Date Of Birth:


Date Of Injury:*


Legal Information

Legal representative?*

Medical Information

Injuries (Please include all details):

Treating Physician:

Address:

City:

Province:

Postal Code:

Employment Information (If Applicable)

Employer Name:

Contact:

Address:

City:

Province:

Postal Code:

Job Title/Occupation:

Phone:

Fax:

Assessments Required

Please select from the following listing of services and disciplines. If there is a service or discipline not otherwise indicated, please use the "other specialty/expertise" text box to type in your request or call us at 1.866.432.7211, fax us at 519.432.7522 or email us.

Type of Referral:

Assessment Type:

Benefits Claimed

Income Replacement Benefits

Caregiver Benefits

Details (i.e. date and amount of OCF 18)

Independent Examinations - Assessment Type

Other Specialty/Expertise

Other Options

Transportation:

Interpreter Required:

Language:

Executive Summary?

Executive Summary

Referral Questions

Attach File

Evolve Standard Questions (Check all that apply)

What is the diagnosis?

Use - Is the diagnosis an aggravation of a pre-existing condition or solely the direct result of this accident?

Use - If the diagnosis is an aggravation of a pre-existing condition, has the Claimant recovered to his/her pre-accident status? If not, please estimate the time such recovery might take.

Use - Please outline any objective organic pathology to substantiate subjective complaints.

Use - What is the claimant’s prognosis?

Use - Please identify the recovery made to date.

Use - Please comment on any other information pertinent to this case.

Use - Do you feel that you have had adequate information provided to you to accurately conclude your assessment opinion?

Use - Q9. Treatment Plan (OCF-18) Review
Are the goods and services, contemplated in the (OCF-18) in question, reasonable and necessary as a direct result of injuries sustained in the accident?

Use - Please provide a detailed rationale and supporting evidence with your response

Use -
Does the claimant’s injury meet the definition of a Minor Injury as defined by the SABS?

Use - Subject to #10 above, does the claimant’s treatment fall within the Minor Injury Guideline (MIG)

Use - If the answer is No to #11 please advise if the insured person’s impairment is predominantly a minor injury but, based on compelling evidence provided by the health practitioner, the insured person does not come within the Minor Injury Guideline because the insured person has a pre-existing medical condition, please provide your recommendations for treatment or assistance to manage these needs.

Use -
Does the claimant currently suffer from an impairment as a direct result of injuries sustained in the accident that causes a substantial inability to engage in the essential tasks of their pre-accident employment?

Use -
Does the claimant currently suffer from an impairment as a direct result of injuries sustained in the accident that causes a complete inability to engage in employment for which they are reasonable suited by education, training or experience?

Use -
Does the claimant suffer from a complete inability to carry on a normal life as a direct result of injuries sustained in the accident?

Use -
Does the claimant suffer a substantial inability to engage in the care-giving activities in which he or she engaged at the time of the accident?

Use - If yes, do you have any recommendations to assist in facilitating a return to care-giving activities?

Use -
Does the claimant suffer from an impairment as a direct result of injuries sustained in the accident that results in the need for attendant care assistants? Please complete a form 1 to detail the level of assistance required in accordance with the SABS regulations.

Use -
Does the claimant suffer a substantial ability to complete his/her pre MVA housekeeping and home maintenance activities?

Use - Please advise us of any complications or extenuating circumstances which may be prolonging the disability, thereby preventing a return housekeeping and home maintenance activities.

Use -
Does the claimant currently suffer from a catastrophic impairment in accordance with the definition detailed in the (OCF-19) in question?

Use - Did the claimant sustain a catastrophic impairment, as defined by the SABS, as a direct result of the accident?

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