Insurance Referral Form – Ontario Only | ARS Insurance Referral Form – Ontario Only

Insurance Referral Form – Ontario Only

Claim Number
Date of Referral	Day: Month: Year:

Referral Source - (Part 1/8)

Name
Email
Adjusters Name
Title
Company
Fax
Address
City
Province
Postal Code

Client Information - (Part 2/8)

Salutation
First Name
Last Name
Address
City
Province (Outside of Ontario, use this form)	Ontario
Postal Code
Home Phone
Other Phone
Date of Birth	Day: Month: Year:
Date of Injury	Day: Month: Year:

Medical Information - (Part 3/8)

Injuries

Treating Physician
Address
City
Province
Postal Code
Phone
Fax

Legal Information - (Part 4/8)

Legal Representative
Title
Company
Phone
Fax
Address
City
Province
Postal Code

Employer Information - (Part 5/8)

Employer Name
Contact
Phone
Fax
Address
City
Province
Postal Code
Job Title/Occupation

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

Other Options - (Part 7/8)

Optional Questions - (Part 8/8)

A: General–Medical or Specified Benefits

1. 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?

2. 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.

3. 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?

4. 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

5. FUNCTIONAL LIMITATIONS: Within the scope of your medical/professional discipline does the claimant currently have any functional limitations and or physical restrictions as a direct result of injuries sustained in the accident? If so, please provide details.

6. TREATMENT/GYM: 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.

B: Minor Injury – Physical

7. a) Within the scope of your medical/professional discipline, please provide your diagnosis of any injury sustained as a result of the motor vehicle accident, noting the impairment in order of severity, with the first being the most severe.

7. b) Do the reported MVA-related complaints correlate with your objective findings?

7. c) Within the scope of your medical/professional discipline, do you concur with the diagnosis and impairment descriptions provided by the health professional(s) to date? If not, please provide a detailed explanation.

7. d) Based on your diagnosis and within the scope of your medical/professional discipline, does the claimant’s impairment fall within the definition of a “minor injury”, as defined in the Minor Injury Guideline? Have you identified any compelling evidence of a pre-existing condition that would prevent the claimant from achieving maximal recovery from the accident related impairment if limited to the medical and rehabilitation limits of $3500.00? Please also comment on any other medical condition(s) stemming from the motor vehicle accident identified during the course of your examination and evaluation.

7. e) Within the scope of your medical/professional discipline, if the impairment identified as a result of the motor vehicle accident is not treatable within the Minor Injury Guideline protocol or within the medical and rehabilitation limits of $3500.00, are the proposed goods and/or services reasonable and necessary? If not, please provide a detailed explanation.

C: Minor Injury – Psychological

8. a) Within the scope of your medical/professional discipline, please provide your diagnosis of any psychological impairment sustained as a result of the motor vehicle accident. If an impairment exists, is it significant and compelling enough to require psychological treatment?

8. b) Within the scope of your medical/professional discipline, do you concur with the diagnosis/impairment descriptions provided by the health professional(s) to date? If not, please provide a detailed explanation.

8. c) Within the scope of your medical/professional discipline, if there is an identifiable psychological diagnosis, are the proposed goods and/or services reasonable and necessary? If not, please provide a detailed explanation.

D: OCF 18 - Treatment

10. Within the scope of your medical/professional discipline, is the treatment plan in dispute reasonable and necessary and required as a direct result of the injuries sustained in the motor vehicle accident after taking into consideration any previous treatment which already might have been provided/received?

11. Within the scope of your medical/professional discipline, are the goods and services detailed in the Treatment & Assessment Plan (OCF-18) reasonable and necessary as a result of injuries sustained in the motor vehicle accident after taking into consideration any previous treatment which already might have been provided/received? Please provide details with your response.

12. Within the scope of your medical/professional discipline, please comment on the reasonableness of the claimant’s current treatment as to the benefit and therapeutic value.

E: OCF 18 - Assessment

13. Within the scope of your medical/professional discipline, is the assessment detailed in the Treatment & Assessment Plan (OCF 18) reasonable and necessary as a result of injuries sustained in the motor vehicle accident after taking into consideration any previous treatment /assessments which already might have been provided/received? Please provide details with your response.

F: Addendum - Paper Review

14. Based on your review of the additional documentation and your physical examination of the claimant on ______, does the information provided affect your opinions and conclusions as outlined in the S.44 Insurer’s Examination report dated ______?

G: Miscellaneous Med/Rehab Questions

15. MEDICATION: Within the scope of your medical/professional discipline, does the claimant currently require any prescription or over the counter medication as a direct result of injuries sustained in the accident? If so, please support your opinion with details of the recommended medication, required dosages and estimated duration of intake.

16. MEDICATION: Within the scope of your medical/professional discipline, is the claimant currently taking any medication that has been prescribed for recovery as a result of the motor vehicle accident? If yes, are there any known adverse effects that would affect the implementation of a safe return to pre-accident activities? Are there any recommendations of alternate medication that could be administered in the aid of a safe return to pre-accident activities?

17. DRIVING/PUBLIC TRANSPORTATION: Within the scope of your medical/professional discipline, does the claimant currently suffer a “complete inability” as a direct result of the motor vehicle accident that prevents him/her from driving or using public transportation? If yes, please provide recommendations that could be implemented for the claimant to return to this activity.

H: Income Replacement Benefits

18. Within the scope of your medical/professional discipline, does the claimant currently suffer a substantial inability to perform the essential tasks of their pre-accident employment/self-employment as a result of injuries sustained in the motor vehicle accident? Please refer to details in the material provided regarding the essential tasks of the claimant’s employment at the time of the accident.

19. Within the scope of your medical/professional discipline, does the claimant currently suffer a substantial inability to perform the essential tasks of the employment the spent the most time in during the 52 weeks prior to the motor vehicle accident, as a direct result of injuries sustained in the accident? Please refer to details in the material provided regarding the essential tasks of the claimant’s employment at the time of the accident

I: Post 104 weeks

20. Within the scope of your medical/professional discipline, does the claimant currently suffer from a “complete inability” to engage in any employment for which he/she is reasonably suited by education, training or experience as a direct result of injuries sustained in the accident? Please refer to file material provided to show the claimant’s transferrable skills, etc.

J: Non-Earner Benefits

21. Within the scope of your medical/professional discipline, does the claimant currently suffer a “complete inability” to carry on a normal life as a result of the injuries sustained as a direct result of the motor vehicle accident?

K: Caregiver Benefits

22. Within the scope of your medical/professional discipline, does the claimant currently suffer a 'substantial inability', as a result of injuries sustained in the motor vehicle accident, to engage in the caregiving activities in which he or she was engaged at the time of the motor vehicle accident? Please refer to details in the material provided regarding the claimants caregiving responsibilities at the time of the accident.

L: Housekeeping and Home Maintenance

23. Within the scope of your medical/professional discipline, does the claimant suffer a substantial inability to perform the housekeeping and home maintenance services he/she normally performed before the accident as a direct result of the injuries sustained in the motor vehicle accident? Please refer to the materials provided which outlines the type of services being claimed. If so, please detail any current medical restrictions and/or functional limitations that prevent these activities from being performed and the recommended hours of assistance per week.

M: Attendant Care

24. Within the scope of your medical/professional discipline, does the claimant suffer from an impairment as a result of injuries sustained in the motor vehicle accident that results in the need for attendant care assistance? Please complete an Assessment of Attendant Care Needs Form 1.

N: Lost Education Benefit

25. Within the scope of your medical/professional opinion, does the claimant suffer from an impairment as a direct result of injuries sustained in the motor vehicle accident that prevents them from continuing in a program of elementary, secondary, post-secondary or continuing education?

O: Catastrophic Impairment

26. Within the scope of your medical/professional discipline, does the claimant suffer from a catastrophic impairment as set out in Part 4 of the Application for Determination of Catastrophic Impairment (OCF-19) as a direct result of the injuries sustained in the motor vehicle accident?

27. Within the scope of your medical/professional discipline, please provide the Whole Person Impairment rating, considering a) the physical impairments only b) as an alternative, the combined rating including psychological impairments

Optional Notes