Insurance Referral Form

Salutation
First Name
Last Name
Address
City
Province
Postal Code
Home Phone
Other Phone
Date of Birth	Day: Month: Year:
Date of Injury	Day: Month: Year:

Legal Representative
Title
Company
Phone
Fax
Address
City
Province (Ontario residents, use this form)
Postal Code

Cardiology Cardiovascular Surgery Chiropractic Dental/Oral ENT Family Medicine Functional (FAE - FCE) General Surgery Geriatric Hepatology Infectious Diseases Internal Medicine Massage Therapy Medicine Neuro-Opthamology Neurological Neuropsychiatric Neuropsychological Neurosurgery Occupational Therapy Oncology Opthamology Orthopaedic Physiatry Physiotherapy Psychiatric Psychological Psychological - Children Psychological - Geriatric Respirology Rheumatology Sleep Disorders Social Worker Urology

Ergonomic Labour Market Analyses Physical Demands Analyses Psycho-Educational Psycho-Vocational Transferable Skills Vocational

In-Home Assessment Job Site Analyses

Other Assessments - Please Specify

Diagnostic Testing (MRI, etc) Executive Summary of Multi-Disciplinary Assessment Opinions Other

If "other," please explain:

DIAGNOSIS: Within the scope of your medical/professional discipline, please provide your diagnosis of any injury sustained as a result of the motor vehicle accident. Do the reported complaints, as they relate to any injury sustained as a direct result of the motor vehicle accident, correlate with your objective findings?

DIAGNOSIS: Within the scope of your medical/professional discipline, do you concur with the diagnosis/impairment descriptions provided by the various health professionals to date? If no, please provide details as to why.

Determine whether a disability exists.

Determine whether any other medical investigations are needed.

PROGNOSIS: Within the scope of your medical/professional discipline, please provide your prognosis of any injury sustained as a direct result of the motor vehicle accident

PRE-EXISTING: Within the scope of your medical/professional discipline, does the claimant suffer from any pre-existing medical condition that existed prior to the motor vehicle accident? If yes, please describe to what extent. Has this been exacerbated as a result of the accident? If so, to what extent? If present, how might this condition affect recovery from injuries sustained in the accident?

TREATMENT: Within the scope of your medical/professional discipline, does the claimant currently require any formal treatment programs or rehabilitation services, (or informal program - for example gym program), to assist in achieving recovery from any impairment present as a direct result of the motor vehicle accident? If so, please provide details to support your opinion to include the specific nature of the service and the estimated frequency and duration.

Notes:

Referral Source - (Part 1/8)

Client Information - (Part 2/8)

Medical Information - (Part 3/8)

Legal Information - (Part 4/8)

Employer Information - (Part 5/8)

Independent Examinations - Assessment Type - (Part 6/8)

Other Assessments - Please Specify

Other Options - (Part 7/8)

Optional Referral Questions (Part 8/8)

Additional Questions

Name
Email
Adjusters Name
Title
Company
Fax
Address
City
Province (Ontario residents, use this form)
Postal Code

Treating Physician
Address
City
Province (Ontario residents, use this form)
Postal Code
Phone
Fax

Employer Name
Contact
Phone
Fax
Address
City
Province (Ontario residents, use this form)
Postal Code
Job Title/Occupation