LOCAL 183 INDUSTRIAL BENEFIT FUND
APPLICATION FOR SHORT TERM DISABILITY BENEFITS
Member Health Management Services
1263 Wilson Avenue, Suite 302 | Toronto, Ontario | M3M 3G3
Tel: 416-240-2104 | Toll Free: 1-866-315-6011 | Fax: 416-240-7047
Email: memberhealthservices@liunacare183.ca | liunacare183.com
Page 2 of 7
How to apply for short term disability benefits?
1. Ensure you meet the eligibility requirements for this benefit listed below
2. Complete and sign the Member Statement (page 1) of the application for short term disability benefits
3. Ensure your current employer completes the Employer Statement (page 2) or provide a copy of the record
of employment (ROE) issued to you after you stopped working.
4. Ensure the physician overseeing your medical care completes the Attending Physician Statement (page 3)
5. Obtain an ROE from your employer and apply for Employment Insurance (EI) Sick Benefits. If you require
assistance in applying for EI benefits, please contact 416-243-6505
6. All three (3) sections of the Application form are required to begin assessing your claim
7. Return the completed application to LiUNAcare Local 183 Member Health Management Services by
Email: [email protected]
Mail: 1263 Wilson Avenue, Suite 302 | Toronto, Ontario | M3M 3G3
Fax: 416-240-7047
Questions: 416-240-2104 or 1-866-315-6011
What are the eligibility requirements?
• You must be a full-time member with Plan A coverage on the date your disability started - this benefit is not
offered to all members and eligibility is subject to what has been negotiated in your collective agreement
• You must be actively at work on the date you become disabled - if you are laid-off, on vacation, unemployed,
or not working for any other reason you are not eligible for this benefit
• Employer contributions must have provided your plan coverage on the day you become disabled - if your
plan coverage was being maintained through self-payments at the onset of your disability, you are not eligible
• You must be under age 65 at the onset of the disability
• Your disability must be a result of a non-occupational illness or injury - If your disability was caused by work,
you must file a claim with the Workplace Safety & Insurance Board (WSIB) - We can assist you with this claim
• If your disability was caused by or contributed by a motor vehicle accident which occurred in the provinces
of Ontario or Quebec, this is excluded, and you are not eligible for this benefit
• There are several other exclusions and limitations – please refer to the benefit plan booklet
• You must be seen by, treated by, and be under the continued care of a licensed physician in Canada
• You must be diagnosed with a bona-fide medical condition which prevents you from working and performing
the essential duties of your pre-disability job
• A maximum benefit of $100 is payable to you if you incur a medical fee in having your initial physician
statement completed, if the claim is approved
• You must be absent from work for more than 7 days (waiting period) to receive this benefit, unless
- your disability is a result of a non-occupational accident - then the waiting period does not apply, or
- you are hospitalized for at least 18 hours - then benefits start on the first day of hospitalization.
Short Term Disability Benefits
Member Health Management Services
1263 Wilson Avenue, Suite 302 | Toronto, Ontario | M3M 3G3
Tel: 416-240-2104 | Toll Free: 1-866-315-6011 | Fax: 416-240-7047
Email: memberhealthservices@liunacare183.ca | liunacare183.com
Page 3 of 7
How does short term disability work?
• Once we receive your completed application, a Member Health Management Services representative will
review your application to determine whether you meet the eligibility requirements for this benefit
• If approved, short term disability benefits are payable at 66
2/3
% of your pre-disability earnings up to a
maximum of $300 per week, less tax withholdings
• If you have signed-up for direct deposit via eClaims, short term disability payment(s) will be automatically
deposited into your bank account via electronic fund transfer. An email will be sent to notify you when a
benefit payment is made. Through eClaims, you can also access your claim history and explanation of benefits
by going to History and selecting Weekly Indemnity. If you have not registered yet, see page 6 for instructions.
• Short term disability benefits are integrated with Employment Insurance (EI) sick benefits - you are required
to apply for this benefit
- while EI benefits are payable, short term disability benefits are frozen
- if you do not qualify for EI, short term disability benefits payments will be issued during this period
provided you submit supporting documentation of your ineligibility for EI benefits
• If approved short term disability benefits are payable on the earliest of the following
- the first day absent from work if the disability is a result of an accident, or
- the first day of hospitalization, or
- the end of the waiting period, or
- after the end of the EI period, if EI starts on the date of disability
• During your disability from work, a Member Health Management Services case manager will work with you
and your treatment providers to monitor your progress, ensure access to appropriate medical care, and
coordinate plan benefits and services to promote your recovery until you are fit to return to work
• In order to remain eligible for short term disability benefits, you must
- remain disabled from working and performing the essential duties of your pre-disability job,
- remain under the continued care of a licensed physician in Canada,
- be compliant with all aspects of your treatment plan including attending all recommended assessments,
investigations, and treatment recommended by your physician and/or your treatment providers,
- communicate regularly with your Member Health Management Services case manager and comply with
any necessary requests required for the ongoing assessment and management of your claim,
- participate in modified return to work plans when available and suitable, and
- immediately notify us of your return to work in any capacity, any change in your work status or availability
to work, if you intend to travel outside Canada, or if there is any change in your medical status
• Short term disability benefits are payable until you
- return to full-time work or any work for pay or profit,
- are deemed fit to return to your pre-disability job,
- attain age 65, or
- reach the maximum benefit duration of 26 weeks of disability (inclusive of the EI period)
• If you return to work but sustain a subsequent disability, a new claim must be filed if you return to work
- ninety (90) days before becoming disabled due to the same or related cause or
- thirty (30) days before becoming disabled due to a different and unrelated cause.
Short Term Disability Benefits
Member Health Management Services
1263 Wilson Avenue, Suite 302 | Toronto, Ontario | M3M 3G3
Tel: 416-240-2104 | Toll Free: 1-866-315-6011 | Fax: 416-240-7047
Email: memberhealthservices@liunacare183.ca | liunacare183.com
Page 4 of 7
Our Services
• Your health matters! At LiUNAcare Local 183, we’re always looking for new ways to service our members
better. Member Health Management Services is your one-stop destination for support on all matters relating
to disability, workers’ compensation, and other medical benefits and services to get you back to health.
• Our team is comprised of disability management specialist and health professionals trained to ensure
members receive medical care focused on recovery and return to work. In addition to helping you access
short term and long term disability benefits, and workers’ compensation benefits, Member Health
Management Services staff work with you in developing a personalized plan and coordinating appropriate
plan benefits and services on an expedited basis.
• Refer to the next page for a list of plan benefits and services available to eligible members and dependents.
Maintaining your benefit coverage while on disability
• Should your coverage terminate because you are unable to work due to disability, you have the option to
continue your coverage by making self-payments to the members’ benefit fund as follows:
- You have the option to make self-payments for a maximum of 12 consecutive months provided you
remain a Member in Good Standing with LiUNA Local 183
- Monthly payments in the amount equal to the cost of the benefits
- Self-payments must be made within 31 days of the termination of your coverage and must be made on
a continuous basis. Retroactive self-payments will not be accepted
- Eligibility for benefits will be conditional on you remaining a Member in Good Standing with Local 183
- You are entitled to the same benefits you enjoyed while you were employed with the exception of Short
Term Disability benefits
- The Trustees may adjust the self-payment amount from time to time.
• For more information refer to the benefit plan booklet or visit liunacare183.com, or contact Member
Services at 416-240-7487 or [email protected]
Other Important Information
• Payment of monthly Union dues is your responsibility to remain in good standing
• Depending on the nature of your condition, speak to your physician about Canada Pension Plan (CPP)
disability benefits. CPP disability benefits will not affect your entitlement to short term disability benefits. If
you have questions regarding the application process, Member Health Management Services can help.
EMBER HEALTH MANA
Member Health Management Services
Member Health Management Services
1263 Wilson Avenue, Suite 302 | Toronto, Ontario | M3M 3G3
Tel: 416-240-2104 | Toll Free: 1-866-315-6011 | Fax: 416-240-7047
Email: memberhealthservices@liunacare183.ca | liunacare183.com
Page 5 of 7
GEMENT SERV
The following benefits and services are available to you to promote recovery and return to health. Not all members are
eligible for the same benefits. The benefits are dictated by the contributions made on their behalf in accordance with
each Collective Agreement and their employment status at the time of contribution. Contact the Administrative Agent.
Plan A Benefits & Services
vCare Virtual Healthcare | liunacare183.com
Avoid visits to walk-in clinics and emergency rooms for non-emergency issues with the vCare Virtual Healthcare platform.
The vCare platform allows members and dependents to connect instantly with a healthcare provider for primary health
concerns via secure text and face-to-face video, 24/7. Virtual follow-ups, prescription refills, specialist referrals, and lab
requisitions offered with no travel time, no wait time, and no parking or transportation costs.
QuikCare Expedited Health Care | 1-844-900-8357 (24/7 helpline)
Normal healthcare wait times can be 8 months to see a specialist and 3 months for diagnostic scans. QuikCare provides
access to expedited healthcare services when your physician refers you for an MRI, CT scan, ultrasounds, or other specialist
consultations including orthopaedic, cardiology, neurology, neurosurgery, gastroenterology, general surgery, ear nose &
throat, ophthalmology, urology, and rheumatology.
Health Care Navigation | 1-866-883-5956
Access to Nurses to help you navigate through the healthcare system and providing a single point of contact during your
treatment. Services include answering questions regarding tests and treatment options, ensuring access to appropriate
treatment, facilitation of diagnostic tests, alternate treatment locations, clinical trials, coordinating doctor-to-doctor
consultations, and coaching on how to improve quality of care and management of your condition.
Cancer Assistance | 1-866-599-2720
Access to Oncology Nurses to help cancer patients navigate through the healthcare system by ensuring medical best
practices are observed, providing expert assessment of treatment approaches, answering patient questions regarding tests
and treatment options, empowering patients to understand their diagnosis, and helping reduce the physical and emotional
impact of cancer.
MyConsult Second Opinion | clevelandclinic.ca
Do you have questions regarding your diagnosis? Through the secure web platform, members and dependents can submit
their health information, records, and test results to a medical expert who will review and help you make an informed
decision about your diagnosis and treatment plan and provide alternatives and second opinions.
Health Coaching | enroll.e-coaching.ca/liuna/183
A confidential one-on-one coaching and support program for those dealing with diabetes, obesity, and cardiovascular
issues, including high blood pressure and high cholesterol, who want to focus on weight management and nutrition. Based
on an online nutritional assessment, a Registered Dietitian or Certified Diabetes Educator will create a personal nutrition
report and meal plan with follow-up coaching sessions to help you achieve your goals.
Self-Help-Works | liunacare.com/selfhelpworks
Make lifestyle goals a reality with this online program that combines principles of cognitive behavioural therapy and health
coaching to help you break-through barriers and tackle smoking, weight, diabetes, alcohol consumption, physical activity,
restoring sound sleep, and reducing stress.
Virtual Home Delivery Pharmacy | liunacare183.com| 1-833-435-5679
Free full-service pharmacy with medication delivery to your home. Medications are sorted by date and time for ease and
convenience. PocketPills works with your prescribing doctor to ensure refills are up to date, with pharmacists actively
managing your medical condition and available via chat, text, or phone to answer any of your questions.
Member Health Management Services
1263 Wilson Avenue, Suite 302 | Toronto, Ontario | M3M 3G3
Tel: 416-240-2104 | Toll Free: 1-866-315-6011 | Fax: 416-240-7047
Email: memberhealthservices@liunacare183.ca | liunacare183.com
Page 6 of 7
mHealth Virtual Mental Health Program | liunacare183.com
This virtual mental health program has been designed to improve mental health resilience and well-being through
specialized psychological treatment called cognitive behavioural therapy. Treatment options for a broad range of
psychological conditions including but not limited to stress, anxiety, depressions, and panic disorders. There is also mental
health assessment tool and resources to improve and achieve mental health wellness.
Member & Family Assistance Program (MFAP) | 1-866-462-8047 (24/7 hotline and crisis line)
Confidential counselling services offered in person, by phone, or online to tackle a variety of issues including stress, anxiety,
depression, bereavement / grief, addiction, family / marital / relationship issues, elder care, and other personal matters
such as life balance and health issues.
Paramedical Benefits - Mental Health Practitioners| liunacare183.com| 416-240-7487 | info@183membersbenefits.ca
Members and eligible dependents may be reimbursed for mental health practitioner services such as clinical psychologists,
psychoanalysts, psychotherapists, or social workers up to a maximum reimbursement of $100 per visit with an overall
combined benefit of $1,000 per calendar year. You can use your Member Advantage Benefit Card to reduce out-of-pocket
expenses, provided your practitioner is registered for electronic claim submission (e-claims).
SMART Program - Substance Management & Recovery Treatment (SMART) | try.alavida.co/liuna183
This virtual and confidential counselling program has been designed to help you tackle your relationship with alcohol or
other substances. Whether you are looking to cut back, quit, or regain control, this program offers a variety of treatment
options and supports from their team of doctors and therapist specialized in addiction to start on your trail towards a
healthier lifestyle.
Other Plan Benefits & Services | liunacare183.com | 416-240-2104 | memberhealthservices@liunacare183.ca
Hospital Cash - if you are admitted to a hospital for at least three consecutive days, you and your eligible dependent may
be eligible for a maximum daily benefit $100 per day up to a maximum of 120 consecutive days.
Critical Illness - if diagnosed with 1 of the eligible conditions, members may be eligible for a benefit payment up to $10,000.
Spouse - $2,500.
Accidental Death & Dismemberment | Life Insurance | + other benefits
Refer to liuncare183.com, Member benefit plan booklet, or contact Member Health Management Services
Plan A Benefits & Services
Paramedical Benefits - Health Practitioners | liunacare183.com| 416-240-7487 | [email protected]
Members and eligible dependents may be reimbursed for health practitioner services such as chiropractic and
physiotherapy* up to a maximum reimbursement of $50 per visit with an overall combined benefit of $1,000 per calendar
year. All practitioners must be licensed and registered with their college. Use your Member Advantage Benefit Card if your
practitioner is registered for e-claims. * MD referral required
Opioid Outpatient Program | 1-877-937-2282 | canatc.ca/locations-2/
Canadian Addiction Treatment Centres (CATC) - the largest addiction treatment provider in Canada - offers Local 183
members priority access to in-person and virtual addiction treatment for those suffering from opioid use disorder. If you
or a loved one are struggling with opioid addiction, contact CATC to learn more about treatment, schedule an initial
assessment with a designated physician, or visit their website for your nearest clinic (walk-ins are welcome). This service
is confidential so do not let privacy concerns get in the way of your wellbeing.
Member Health Management Services
1263 Wilson Avenue, Suite 302 | Toronto, Ontario | M3M 3G3
Tel: 416-240-2104 | Toll Free: 1-866-315-6011 | Fax: 416-240-7047
Email: memberhealthservices@liunacare183.ca | liunacare183.com
Page 7 of 7
Direct Deposit
Short Term Disability Benefits
Already have EFT Direct Deposit set-up…
Then you are all set! Short term disability benefit payments will be automatically deposited
directly into the authorized bank account via electronic fund transfer (EFT). An email will be
sent to you confirming when benefit payments have been made. In addition, you will have
access to your short term disability claim history and explanation of benefits and can submit
documents securely through the LiUNAcare Local 183 eClaims mobile app and website.
Haven’t Registered yet?
Download the LiUNAcare Local 183 eClaims app from the App Store or
Google Play and follow the registration instructions. Make sure you have your
Member Advantage benefit card handy as you will be asked to provide your
group number (the first 6 digits of your card) and certificate number (the
remaining 10 digits).
You can also check out a short instructional how-to video at www.liunacare183.com.
Prefer If you prefer to register online - go to www.liuncare183.com and look for the eClaims link at the top, right-
hand corner of your screen, click register account, and follow a few simple steps.
Once I’m registered, what’s next?
Complete the attached Application for EFT (CAD) Direct Deposit form in full and send it to us via
Email at info@183membersbenefits.ca
Fax at 416-240-7488
Questions - email or call us at 416-240-7487
What if I’m not registered for direct deposit?
You will receive weekly short term disability benefit payments via cheque until you become registered.
EFT – Electronic Funds Transfer
Application for EFT (CAD) Direct Deposit
Submit ' to:
LiUNA!care Local 183| 1263 Wilson Ave. Suite 205, East Wing Toronto, ON M3M 3G2| Tel: 416-240-7487| Email: [email protected]
A. Member!Information!(Please'Print)
First'Name'
Address'
Date'of' Birth'(mm/dd/yy)'
City'
Province'
Postal'Code'
Union'ID'
Country'
Email'Address'
Telephone'No.'
Cell'No.'
B. Account Information
Account Holder Name(s):
Transit'No:' Bank'No:' Account'No:'
I/We'Acknowledge'that'this'agreement'is'provided'for'the'Benefit'of'the'“Payee”'and'“Processing'Institution”'and'is'provided'in'consideration of the
Processing Institution agreeing to process credits into'the'Account'with'the'Processing'Institution'in'accordance'with'the'Rules'of'the'Canadian'Payments'
Association'(the'“CPA'Rules”).'
By'signing'this'agreement,'I/We'request'my/our'benefits'to'be'paid'through'electronic'funds'transfer'(direct'deposit)'into'this'account.''This'
authorization'may'be'cancelled'at'any'time'upon'written'notice'by'me/us.'I/We'warrant'and'guarantee'that'the'Person(s)'whose'signature(s)'is/are'
required'to'sign'on'the'Account'have'signed'the'Agreement.'
Note:!If!only!one!signature!is!required!for!this!account,!then! only! one!Payee!is!needed!to!sign.!However,!if!two!or!more!signatures!are!
required,!then!both!or!all! payees!must' sign.!
Payee' Signature:'' __________________________________________________' ' Payee' (2)' Signature:'
Date:' 'Date:'
Please'complete' in' full,'print,'sign,'and'return'by'fax:'(416) 240-7488'or'by'email' at [email protected]
C. Authorization
New Authorization
Change to Existing Authorization
Last'Name'
Application for Short Term Disability Benefits
Member Health Management Services | 1263 Wilson Avenue, Suite 302 | Toronto, ON | M3M 3G3
Tel: 416-240-2104 | Toll Free: 1-866-315-6011 | Fax: 416-240-7047
Email: memberhealthservices@liunacare183.ca | web: liunacare183.com
IBF - ST - Page 1 of 3
MEMBER STATEMENT
All three (3) sections of this application must be completed, signed, and submitted to initiate your claim for Short Term Disability benefits:
1. Member Statement
2. Employer Statement (or Record of Employment) completed by current employer
3. Attending Physician Statement completed by the Physician overseeing your care
If any section of this application is not completed or portions are not answered fully, the assessment of your claim may be delayed. You are required
to apply for Employment Insurance (EI) Sickness Benefits as Short Term Disability benefits are not payable during the period payable by EI benefits.
Member Information
Last Name First Name
Union ID Number
Address
Date of Birth (mm/dd/yyyy)
Town/City Province Postal Code
Telephone Number
Email Address
Cell Phone Number
Absence Information
Job Title
Last day worked (mm/dd/yyyy)
First day absent from work due to medical condition
Return to work date
Expected return to work date
Is your condition due to an accident?
No Yes
Accident date
Is this due to a motor vehicle accident?
No Yes
Is the accident or medical condition work-related?
No Yes
Describe the nature of your medical condition and/or how the accident occurred (time, location, activity being performed at time of injury)
Have you applied for or are you receiving any of the following Benefits?
Employment Insurance (EI) Benefits
Applied
Approved
Denied
Workplace Safety & Insurance Board (WSIB) Benefits
Applied
Approved
Denied
Motor Vehicle Accident Insurance Benefits
Applied
Approved
Denied
Canada Pension Plan (CPP) Disability Benefits
Applied
Approved
Denied
Any other Disability or Income Continuation Benefits
Applied
Approved
Denied
During your absence, will you be working or receiving income from another employer or self-employment?
No Yes, Describe
Member Declaration & Authorization for Release of Information
I certify that the information presented is true, correct, and complete. I understand that for the duration of this claim, I must immediately notify LiUNAcare Local 183
Member Health Management Services of my return to work in any capacity, my receipt of any employment income, and/or any change in my status as it relates to my
ability to work or entitlement to short term disability benefits. LiUNAcare Local 183 is administered by Benefit Plan Administrators Limited (BPA) on behalf of the Local
183 Industrial Benefit Fund. I hereby authorize BPA, administrators of the Local 183 Industrial Benefit Fund, and its subsidiaries, to collect, use, and exchange any and
all information and documentation requested by BPA regarding or relating to my medical or mental health condition for the purpose of assessing and managing my
claim for short term disability benefits and access to other benefits and services provided by the Local 183 Industrial Benefit Fund. This includes authorizing any
physician, health care professional, hospital, public or private institution, my employer(s), and Union to provide to BPA any information required for the assessment or
management of my claim for short term disability benefits. I authorize BPA to share with TeksMed Services Inc., third party provider, any and all information collected
for the purpose of coordinating diagnostic scans and/or specialist consultations if placed on a medical wait list greater than 21 days, should I be eligible for this benefit.
I authorize TeksMed Services Inc. to release the results of my diagnostic scan(s) and or specialist consultation(s) to BPA for the assessment and management of my
claim for short term disability benefits. I authorize BPA to share with CAREpath, third party provider, any and all information collected for the purpose of providing me
individualized nurse case management and health care navigation services should I be eligible for this benefit. I also authorize BPA to share with my Long Term Disability
Insurer any and all information and documentation collected should I be eligible for Long Term Disability benefits. All personal information will be treated in a highly
confidential manner. It is understood that this authorization is valid from the date hereof through my return to work. This authorization may be withdrawn at any time
upon receipt of written notification to BPA. I confirm that a photocopy or electronic copy of this authorization shall be as valid as the original. By signing below, I consent
to the collection, use, and disclosure of my personal information as stated above.
Member Signature
Date
Application for Short Term Disability Benefits
Member Health Management Services | 1263 Wilson Avenue, Suite 302 | Toronto, ON | M3M 3G3
Tel: 416-240-2104 | Toll Free: 1-866-315-6011 | Fax: 416-240-7047
Email: memberhealthservices@liunacare183.ca | web: liunacare183.com
IBF - ST - Page 2 of 3
EMPLOYER STATEMENT
LiUNAcare Local 183 Member Health Management Services is responsible for reviewing medical absences to assess eligibility to Short Term Disability
benefits offered through the Local 183 Industrial Benefit Fund and coordinating other plan benefits and services to assist Members in their recoveries
and return to work. Please complete the following information in full and return directly to the Member or send to LiUNAcare Local 183 Member
Health Management Services via fax at 416-240-7047 or email at memberhealthservic[email protected]. Please attach any additional information
to help us understand the Member’s absence, work duties, or physical demands of the job.
Member Information
Member’s Last Name Member’s First Name
Union ID Number
Employment Information
Job Title
Date of hire (mm/dd/yyyy)
Gross weekly earnings
Member’s Normal Work Schedule:
Day of Week Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Hours
Number of hours normally worked per week:
Provide a description of the Member’s work duties or attach a job description or physical demands assessment
Last day worked
First day absent from work
Actual or expected return to work Date
Reason for work absence
Medical Lay-
Off
Dismissed Quit Leave Unknown Other
Has the Member received pay after the last day worked?
Yes No
If yes, provide final day paid
Was the Member recalled back to work but unable due to medical reasons?
Yes No
If yes, provide date of recall
Are modified duties available?
Yes No
Are modified hours available?
Yes No
Declaration
I certify that the above information is true, correct, and complete.
Employer Contact Name
Title
Employer
Telephone
Employer Signature
Date
Please complete and return this form to
LiUNAcare Local 183 Member Health Management Services
1263 Wilson Avenue, Suite 302 | Toronto, ON | M3M 3G3
Fax: 416-240-7047 | Email: memberhealthservices@liunacare183.ca
Application for Short Term Disability Benefits
Member Health Management Services | 1263 Wilson Avenue, Suite 302 | Toronto, ON | M3M 3G3
Tel: 416-240-2104 | Toll Free: 1-866-315-6011 | Fax: 416-240-7047
Email: memberhealthservices@liunacare183.ca | web: liunacare183.com
IBF - ST - Page 3 of 3
ATTENDING PHYSICIAN STATEMENT
LiUNAcare Local 183 Member Health Management Services is responsible for reviewing medical absences to assess eligibility to Short Term Disability benefits offered
through the Local 183 Industrial Benefit Plan. Please complete the following information in full and return directly to your patient or send to LiUNAcare Local 183
Member Health Management Services via fax at 416-240-7047 or email at memberhealthservices@liunacare183.ca. Please attach any additional information regarding
the nature or extent of the patient’s medical status or absence from work. Any fees associated with the completion of this form is the responsibility of the patient.
Patient Information
Patient’s Last Name Patient’s First Name
Date of Birth (mm/dd/yyyy)
Medical Information
Date symptoms first appeared (mm/dd/yyyy)
Date of first visit after work absence
First date of work absence due to condition
Is the condition a result of an accident?
No Yes
Is the accident or condition work-related?
No Yes
Is condition due to a motor vehicle accident?
No Yes
Primary Diagnosis
Secondary Diagnosis and/or Complications
Functional Abilities - current physical and cognitive abilities
Hospitalization
No
Yes
Admittance Discharge
Surgery
No
Yes
Surgery Type Date
General Anesthesia
Specialist
No
Yes
Name/Type Date Pending
Diagnostics
No
Yes
Type Date
Pending
If currently on a wait list for specialist consult or a diagnostic assessment attach requisition so we may coordinate service on an expedited basis
Treatment Plan - therapies, tests/investigations, referrals, specialty programs
Medications - name, dosage, and frequency
Compliance
Yes
No, describe Patient not competent to manage own affairs
Prognosis & Return to Work goals - If patient fit to return to work with modifications, provide recommendations for return (restrictions, days per week, hours per day)
Next assessment date
Frequency of visits
Actual or estimated return to work date
Please attach any additional information that would give us a better understanding of the patient’s condition, treatment needs, and abilities
Declaration
I certify that the above information is true, correct, and complete.
Physician’s Name
Telephone Number
Physician’s Address
Fax Number
Physician’s Signature
Date
