Injuries
Ergonomic Labour Market Analyses Physical Demands Analyses Psycho-Educational Psycho-Vocational Transferable Skills Vocational
In-Home Assessment Job Site Analyses
Diagnostic Testing (MRI, etc) Executive Summary of Multi-Disciplinary Assessment Opinions Other
If "other," please explain:
Transportation Yes No To Be Determined
Interpreter Required Yes No
Language
Benefits Claimed
Short-Term Disability Benefits Sick Pay Benefits Long-Term Disability Benefits
Within the scope of your medical/professional discipline, please provide your prognosis for any injury sustained as a direct result of the motor vehicle accident.
Within the scope of your medical/professional discipline, has the claimant achieved maximum medical recover (MMR)? If not please provide your opinion as to when this may occur.
Treatment Plan (OCF-18) Review - Within the scope of your medical/professional discipline, are the goods and services detailed 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. If in your opinion these services are not required, please provide details as to any other medical/rehabilitation the individual may require as a direct result of injuries sustained the accident.
Application for Approval of an Assessment or Examination (OCF-22) Review - Within the scope of your medical/professional discipline is the assessment(s) as detailed in the (OCF-22) 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.
Income Replacement Benefit - Employed at the Time of Accident - Within the scope of your medical/professional discipline, 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?
Income Replacement Benefit - Post-104 Week Entitlement - Within the scope of your medical/professional discipline, 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 reasonably suited by education, train or experience?
Non-Earner Benefit - Within the scope of your medical/professional discipline, does the claimant suffer from a complete inability to carry on a normal life a direct result of injuries sustained in the accident? For the purpose of the relevant benefits regulation, 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 a person ordinarily engaged before the accident.
Caregiver Benefit - Within the scope of your medical/professional discipline, does the claimant suffer from an impairment as a direct result of injuries sustained in the accident that causes a substantial inability to engage in the caregiving activities in which they engaged at the time of the accident? If so, please detail any medical restrictions and/or functional limitations present that prevent these activities from being performed, the recommended hours of assistance per week required and when the claimant should be capable of performing them independently.
Attendant Care Benefit - Within the scope of your medical/professional discipline, does the claimant suffer from a impairment as a direct result of injuries sustained in the accident that results in the need for attendant care assistance? The response must include a fully completed Form 1 to precisely detail the level of assistance required.
Housekeeping & Home Maintenance Benefit - Within the scope of your medical/professional discipline, does the claimant suffer from a impairment as a direct result of injuries sustained in the accident that causes a substantial inability to perform housekeeping and home maintenance services they normally perform before the accident? If so, please detail and current medical restrictions and/or functional limitations that prevent these activities from being performed, the recommended hours of assistance required per week and when the claimant should be able to perform them independently.
Catastrophic Impairment (OCF-19) Review - Within the scope of your medical/professional discipline, does the claimant currently suffer from a catastrophic impairment in accordance with the definition detailed in the (OCF-19) in question? Please provide a detailed rationale and supporting evidence with your response.
