Ontario Accident Benefits

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    Medical Information

    Injuries (Please include all details):

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    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)

    Should the OCF-18 under review be addressed regardless if the insured’s medical rehabilitation has been determined to fall within the MIG?

    Independent Examinations - Assessment Type

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    Executive Summary?

    Executive Summary

    Referral Questions

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    Evolve Standard Questions (Check all that apply)

    Within the scope of your practice what injuries did the claimant sustain as a result of the MVA?

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

    Use -Is there a documented pre-existing condition, and if so, does the documented pre-existing condition prevent the claimant from achieving maximal recovery from the accident related impairment if limited to the medical and rehabilitation limits of $3500.00?

    Use - If the claimant's medical and rehabilitation does not fall within the Minor Injury Guideline,
    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? Please provide a detailed rationale and supporting evidence with your response.

    Use -If yes, are the costs associated with the proposed goods and services reasonable and necessary?

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

    Use -If yes, are the costs associated with the proposed goods and services reasonable and necessary?

    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? Please provide detailed rationale and supporting evidence with your response.

    Use - If Yes to the above, is the claimant capable of returning to work on a graduated basis? What are your recommendations for returning the claimant to 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 any employment for which they are reasonable suited by education, training or experience? Please provide detailed rationale and supporting evidence with your response.

    Use -If yes to the above, do you have any recommendations to assist in facilitating a return to employment?

    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? (As per the SABS, a person suffers a complete inability to carry on a normal life as a result of an accident if, and only if, as a result of the accident, the person sustains an impairment that continuously prevents the person from engaging in substantially all of the activities in which the person ordinarily engaged before the accident.) Please provide detailed rationale and supporting evidence with your response.

    Use -If yes, do you have any recommendations to assist in facilitating a return to their Activities of Daily Living?

    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? Please provide detailed rationale and supporting evidence with your response.

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

    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? (As per the SABS, a person suffers a complete inability to carry on a normal life as a result of an accident if, and only if, as a result of the accident, the person sustains an impairment that continuously prevents the person from engaging in substantially all of the activities in which the person ordinarily engaged before the accident.) Please provide detailed rationale and supporting evidence with your response.

    Use -If yes, do you have any recommendations to assist in facilitating a return to their Activities of Daily Living?

    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 assistance? Please complete a Form 1 to detail the level of assistance required in accordance with the SABS regulations. Please provide a detailed rationale and supporting evidence with your response.

    Use -
    Does the claimant suffer a substantial ability to complete his/her pre MVA housekeeping and home maintenance activities? Please provide detailed rationale and supporting evidence with your response.

    Use -If Yes to the above, what are your recommendations for returning the claimant to their pre-accident housekeeping and home maintenance activities? Please advise us of any complications or extenuating circumstances which may be prolonging the disability, thereby preventing a return to housekeeping and home maintenance activities.

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

    Use -2.Did the claimant sustain a catastrophic impairment, as defined by the SABS, as a direct result of the accident?

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