Treatment Confirmation Form OCF-23
Contents
1. Return this form to Treatment Confirmation Form OCF 23 Use this form for accidents that occur on or after October 1 2003 Claim Number Policy Number Date of Accident YYYYMMDD To the Applicant Please provide information for the completion of Parts 1 2 and 3 After your health practitioner has reviewed your Treatment Confirmation Form with you sign Part 8 Your health practitioner will complete all other parts of the form Collection use and disclosure of this information are subject to all applicable privacy legislation Additional disclosure and consent may be required depending on the manner in which the information is used and disclosed As indicated on the form all attachments are sent directly to the insurer All fields must be completed subject to the following exceptions required if known at least one field in this section optional To the Initiating Health Practitioner For accidents that occur before September 1 2010 this form is to be used for goods and services provided in accordance with the Pre approved Framework Guideline for Grade I and II Whiplash Associated Disorders PAF Guideline For accidents that occur on or after September 1 2010 this form is to be used for goods and services provided in accordance with the Minor Injury Guideline A Health Practitioner who is authorized by law to treat the impairment who is authorized unde2. Payment by auto insurer is secondary to available collateral benefits Part 11 Sub Total Total Briefly explain why the goods and services in Part 11 are being proposed and the treatment goal Are there any attachments Yes No If yes how many _______ Send any attachments directly to the insurer I waive the requirement of the Applicant s signature Part 12 I have reviewed this Treatment Confirmation Form and based upon the information provided Signature of I confirm that the policy referred to in Part 2 was in force at the time of the accident Insurer If other goods or services requiring insurer approval have been proposed in Part 11 I Approve Partially approve Do not approve explanation to follow or attached explanation to follow or attached Name of Adjuster please print Signature of Adjuster Date YYYYMMDD To the insurer Please provide a copy of this page to the Applicant and the Initiating Health Practitioner indicated in Part 4 Effective Date 2014 11 01 FSCO 1209E 3 OCF 23 Page 4 of 4 PRINT RESET SAVE
3. Guideline if the accident occurred on or after September 1 2010 I have reviewed the proposed treatment with the applicant I certify that the information provided is true and correct I understand that it is an offence under the Insurance Act to knowingly make a false or misleading statement or representation to an insurer under a contract of insurance I further understand that it is an offence under the federal Criminal Code for anyone by deceit falsehood or other dishonest act to defraud or attempt to defraud an insurance company This information will be used for processing payments of claims identifying and analysing the nature effects and costs of goods and services that are provided to automobile accident victims by health care providers and detecting and preventing fraud Name of Initiating Health Practitioner please print Signature of Initiating Health Practitioner Date YYYYMMDD To the Health Practitioner Please complete the following information based on your most recent examination of the applicant named above and return the form to the insurance company listed in Part 2 Please print clearly Provide a description list most significant first and associated ICD 10 CA code for injuries and sequelae that are the direct result Part 5 of the automobile accident refer to the User manual at www hcaiinfo ca for ICD 10 CA coding information Injury and Injury Description Injury Code Sequelae Information Part 6 Prior an
4. asp Name of Applicant or Substitute Decision Maker please print Signature of Applicant or Substitute Decision Maker Date YYYYMMDD Effective Date 2014 11 01 FSCO 1209E 3 OCF 23 Page 3 of 4 Applicant Name Policy Number Provider Name OCF 23 INSURER FAX BACK Claim Number Provider Fax Date of Accident Part 9 Guideline Services Category Description Maximum Fee Estimated Fee Identify which Guideline is applicable Supplementary Goods amp Services Other Pre approved Services including radiology Part 9 Sub Total Part 10 Other Health Providers required only if Part 11 services are rendered by other providers Provider Reference A B C D Provider Type Provider Last Name First Name Regulated College Registration Number Unregulated Hourly Rate if applicable or if applicable blank Note Refer to the User manual at www hcaiinfo ca for ICD 10 CA coding information Part 11 Other Goods or Services Within the Guideline Requiring Insurer Approval Applicable for accidents that occur before September 1 2010 Description Code Attribute Provider Reference Estimated Quantity Measure Cost Note Refer to the User Manual coding guidelines posted at www hcaiinfo ca Attributes codes are used to further qualify the service codes and are described in the manual
5. d Concurrent Conditions a Was the applicant employed at the time of the accident Yes No b Prior to the accident did the applicant have any disease condition or injury that could affect his her response to treatment for the injuries identified in Part 5 No Unknown Yes please explain c If Yes to b above did the applicant undergo investigation or receive treatment for this disease condition or injury in the past year No Unknown Yes please explain and identify provider if known a Have you identified any barriers to recovery that may affect the success of this treatment for this particular applicant For Part 7 assistance in identifying barriers to recovery please refer to the user manual at www hcaiinfo ca Barriers to No Yes please explain Recovery Effective Date 2014 11 01 FSCO 1209E 3 OCF 23 Page 2 of 4 Part 8 Signature of Applicant I have reviewed this form I have been informed about and agree with the proposed treatment I certify that to the best of my knowledge the information I have provided is accurate Payment for this treatment is pre approved and or subject to the approval of the insurer For services requiring insurer approval I understand that if I undertake those services prior to approval by the insurer I may be responsible to my provider for any goods or services provided All services are subject to coverage issues or exclusions I consent to sharing of personal infor
6. e that is potentially available to cover partially cover these goods and services MOH Is there Ministry of Health and Long Term Care MOH coverage for any goods and services included in this plan Yes No Not applicable Other Insurer 1 Other Insurer Name Other Insurance Plan Or Policy Number Name of Plan Member Other Insurer s Identifier Other Insurer 2 Other Insurer Name Other Insurance Plan Or Policy Number Name of Plan Member Other Insurer s Identifier Effective Date 2014 11 01 FSCO 1209E 3 OCF 23 Page 1 of 4 Queen s Printer for Ontario 2014 Part 4 Signature of Initiating Health Practitioner I am not the first Initiating Health Practitioner Name of Initiating Health Practitioner please print College Registration Number You are a Chiropractor Dentist Nurse Practitioner Occupational Therapist Physician Physiotherapist Facility Name if applicable HCAI Facility Registry Number FSCO Licence Number if applicable Service Address City Province Postal Code Telephone Number Extension Fax Number Email Address I certify that the goods and services contemplated are reasonable and necessary for the treatment and rehabilitation of the applicant for the injuries identified in Part 5 and the treatment proposed is in accordance with the PAF Guideline if the accident occurred before September 1 2010 or the Minor Injury
7. mation between my Initiating Health Practitioner and my insurer If this OCF 23 is not being completed by the first Initiating Health Practitioner I consent to the insurer contacting the first Initiating Health Practitioner to determine the amount of the Guideline goods and services that have been consumed TO THE INSURER TO WHOM THIS APPLICATION IS BEING SUBMITTED I UNDERSTAND that you and persons acting for you will collect personal information and personal health information about me that is related to my claims for accident benefits arising out of the accident described in this application and that all such information will be collected directly from me or from any other person with my consent I ALSO UNDERSTAND that you and persons acting for you will collect information about my driving record automobile insurance policy history and automobile insurance claims history if they exist I ALSO UNDERSTAND that if I am the holder of an automobile insurance policy you and persons acting for you will collect the driving record automobile insurance policy history and automobile insurance claims history of any listed drivers on my automobile insurance policy or other drivers whom I have permitted to drive my automobile I ALSO UNDERSTAND that the information described above will be collected and used only as reasonably necessary for the purposes of Investigating my claims and processing my claims as required by law including the Ontario A
8. r the applicable Guideline to complete this form and who will be the Health Practitioner responsible for providing the goods and services described in this form must sign Part 4 Consent It is the responsibility of Health Practitioners to ensure that their collection use and disclosure of information submitted are authorized by a consent form The Ontario Claims Form 5 OCF 5 Permission to Disclose Health Information may be used as a consent form Date Of Birth YYYYMMDD Gender Telephone Number Extension Part 1 Male Female Applicant Last Name Information First Name Middle Name To be provided by the applicant Address City Province Postal Code Part 2 Insurance Company Information To be provided by the applicant Company Name City or Town of Branch Office if applicable Adjuster Last Name Adjuster First Name Adjuster Telephone Extension Adjuster Fax Name of Policy Holder Same as Applicant OR Policy Holder Last Name Policy Holder First Name Part 3 Other Insurance Information To be completed by the Initiating Health Practitioner with Information from the Applicant OTHER INSURANCE Is there other insurance coverage for any goods and services listed in this Treatment Confirmation Form I have made reasonable enquiries of the applicant and have determined that NO There is no other insurance coverage identified for these goods and services YES There is other insurance coverag
9. ther sources and may analyze this information for the limited purpose of preventing detecting or suppressing fraud I CONSENT and if I am the holder of an automobile insurance policy declare that I have obtained consent from the listed drivers on my policy and any other drivers whom I have permitted to drive my automobile to you collecting using and disclosing this information in the manner described above but no more of such information than is reasonably necessary to meet the legitimate purpose of such collection use or disclosure I UNDERSTAND that if I have any questions about this consent I am free to consult with my insurance company representative or legal advisor before signing this document I AM ALSO AWARE that you and persons acting for you may be required or permitted by law to disclose this information to others without my knowledge or consent I certify that the information provided is true and correct I understand that it is an offence under the Insurance Act to knowingly make a false or misleading statement or representation to an insurer under a contract of insurance I further understand that it is an offence under the federal Criminal Code for anyone by deceit falsehood or other dishonest act to defraud or attempt to defraud an insurance company To obtain further information about how your consent relates to pooling and data analytics to prevent and detect fraud please visit http www ibc ca en privacy terminology
10. utomobile Policy Obtaining or verifying information relating to my claims in order to determine entitlement and the proper amount of payment Recovering payment from insurers and others liable in law for amounts that you pay in connection with my claims Identifying and analyzing the nature and costs of goods and services that are provided to automobile accident victims by health care providers Preventing detecting and suppressing fraud Compiling anonymized statistics for government agencies and Assessing underwriting risks and claims experience I ALSO UNDERSTAND that you and persons acting for you may disclose this information to the following persons or organizations who may collect and use this information only as reasonably necessary to enable you or them to carry out the purposes described above Insurers insurance adjusters agents and brokers employers health care professionals hospitals accountants financial advisors solicitors organizations that consolidate claims and underwriting information for the insurance industry fraud prevention organizations other insurance companies the police databases or registers used by the insurance industry to analyze and check information provided against existing information and my agents or representatives as designated by me from time to time I ALSO UNDERSTAND that you and persons acting for you may pool this information with information from o
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