Treatment and Assessment Plan (OCF-18)
Contents
1. Return this form to a ee ee 8 es Treatment and Assessment Plan OCF 18 Use this form for accidents that occur on or after November 1 1996 Claim Number Policy Number Date of Accident YYYYMMDD NOTE A Treatment and Assessment Plan OCF 18 is not required to make the following claims ambulance or other goods or services provided on an emergency basis not more than 5 business days after the accident drugs prescribed by a regulated health professional goods with a cost of 250 or less per item dental goods or services submitted on the Standard Dental Claim Form If this is an impairment that comes within the Minor Injury Guideline for accidents that occurred on or after September 1 2010 or within a Pre approved Framework Guideline for accidents that occurred before September 1 2010 an OCF 23 Treatment Confirmation Form is required instead of this form To the Applicant Please provide information for the completion of Parts 1 and 2 and 3 After your regulated health professional has reviewed your Treatment and Assessment Plan To the Regulated Health Professional Facility To the extent possible this Treatment and Assessment Plan should include all goods and services contemplated by the regulated health professional referred to in Part 5 with you sign Part 10 Your regulated health professional will complete all other parts of the form Coll2. The Regulated Health Professional referred to in Part 5 will contact each of the health care providers listed in Part 11 and provide details of the services and other charges that have been approved and are payable under this Treatment and Assessment Plan Effective date 2012 11 01 FSCO 1207E 1 OCF 18 Page 5 of 5 Queen s Printer for Ontario 2012
3. a L Chiropractor T 7 7 7 z O Dentist Facility Name if applicable AISI Facility Number if applicable a O Nurse Practitioner O Occupational Therapist Address O Optometrist L Physician City Province Postal Code L Physiotherapist O Psychologist Telephone Number Extension Fax Number O Speech Language Pathologist Email Address For accidents that occurred before September 1 2010 Is this an impairment referred to in a Pre approved Framework PAF Guideline O Yes O No If yes please explain in accordance with the PAF Guideline and with express reference to the provisions of the PAF Guideline on which you rely why this OCF 18 Treatment and Assessment Plan is being submitted instead of an OCF 23 Treatment Confirmation Form For accidents that occur on or after September 1 2010 Is this impairment predominantly a minor injury as referred to in the Minor Injury Guideline O Yes O No If yes please explain and provide compelling evidence why the applicant does not come within the Minor Injury Guideline due to a pre existing medical condition that will prevent the applicant from achieving maximal recovery from the minor injury if the applicant is subject to the 3 500 limit or is limited to the goods and services authorized under the Minor Injury Guideline Send any attachments directly to the insurer confirm that to the best of my knowledge the information in this Treatment and Assessment Plan is accurate the T
4. M THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT 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 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 Name of Regulated Health Professional please print Signature of Regulated Health Professional Date YYYYMMDD Effective date 2012 11 01 PRINT RESET SAVE OCF 18 FSCO 1207E 1 Page 2 of 5 Queen s Printer for Ontario 2012 To the Regulated Health Professional referred to in Part 5 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 E T Part 6 Provide a description list most significant first and associated ICD 10 CA code for complaints injuries and sequelae that are the direct result of the automobile accident refer to the User manual at www hcaiinfo ca for ICD 10 CA coding information Injury and Sequelae Description Gade Information EEE Part 7 a 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 Prior and Part 6 silat O No O Unknow
5. atment and Assessment Plan is subject to the approval of the insurer In the event that my insurer does not agree to pay for all the goods and services contemplated in this Treatment and Assessment Plan understand that an examination may be required to determine my eligibility to the goods and services outlined or this Treatment and Assessment Plan In the event that an examination is requested authorize my insurer and my health care providers to give the person identified by the insurer to review this application only such information relating to my health condition treatment and rehabilitation received as a result of the accident as is reasonably required for the purposes of determining my eligibility to benefits As required by law a copy of the examination report as well as the insurance company s determination will be sent to me Subject to the Statutory Accident Benefits Schedule in those circumstances where prior approval is required understand that if undertake any of the proposed services prior to approval by the insurer may be responsible for payment to my provider for any of the services rendered on my behalf CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT 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 FURTHER UNDERSTAND THAT IT IS AN OFFENCE UNDER THE FEDERAL CRIMINAL CODE for any
6. ection use and disclosure of this information are subject to all applicable privacy A health practitioner i e chiropractor dentist nurse practitioner occupational therapist optometrist physician physiotherapist psychologist speech language pathologist must sign Part 4 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 Consent It is the responsibility of regulated health professionals to ensure that their collection use and disclosure of information submitted are authorized by a consent form Ontario Claims Form 5 OCF 5 Permission to Disclose Health Information may be used as a consent form All fields must be completed subject to the following exceptions required if known at least one field in this section optional pene Part 1 Date Of Birth YYYYMMDD Gender O Male O Female Telephone Number Extension Applicant Information Last Name the applicant FirstName Middle Name Address City Province Postal Code E S Part 2 Insurance Company Name City or Town of Branch Office if applicable Insurance Company Adjuster Last Name Adjuster First Name Information Adjuster Telephone Extension Adjuster Fax To be provided by the applicant Name of Policy Holder Policy Holder Las
7. er qualify the service codes and are described in the manual if app Payment by auto insurer is secondary to available collateral benefits Auto Insurer Total Please indicate any additional comments regarding proposed goods and services Are there any attachments O Yes O No If Yes how many Send any attachments directly to the insurer UO waive the requirement of the Applicant s signature Part 13 Signature of have reviewed this Treatment and Assessment Plan and based upon the information provided Insurer O Approve this Treatment and Assessment Plan O Partially approve O Do not approve The Statutory Accident Benefits Schedule states that the insurer shall within 10 business days of receiving this Treatment and Assessment Plan give the applicant a notice stating the goods and services contemplated by the Treatment and Assessment Plan for which the insurer will or will not pay Name of Adjuster please print Signature of Adjuster Date YYYYMMDD To the insurer Please provide a copy of this page to the applicant the Health Practitioner indicated in Part 4 and the Regulated Health Professional indicated in Part 5 Note The fee for completing this form is not a health care benefit of the Ontario Ministry of Health and Long Term Care This fee should be billed to the insurer directly
8. less waived by insurer Effective date 2012 11 01 FSCO 1207E 1 Goals i Identify the goal s in regard to the applicant s impairment s symptom s or pathology that this Treatment and Assessment Plan seeks to achieve O pain reduction O increase in strength a O increased range of motion O other s not applicable please specify and ii Select the functional goal s that this Treatment and Assessment Plan seeks to achieve return to activities of normal living return to pre accident work activities O return to modified work activities O other s not applicable please specify b Evaluation i How will progress on the goal s in a i and a ii be evaluated ii If this is a subsequent Treatment and Assessment Plan what was the applicant s improvement at the end of the previous plan based on your evaluation method Send any attachments directly to the insurer c Barriers to recovery i Have you identified any other barriers to recovery O No O Yes please explain L no ii Do you have any recommendations and or strategies to overcome these barriers O Yes please explain d Concurrent Treatment Are you aware if any concurrent treatment not included in this Treatment and Assessment Plan will be provided by any other provider facility L No O Yes please explain have reviewed and agree with this Treatment and Assessment Plan understand that payment for this Tre
9. n O Yes please explain onditions If Yes to a above did the applicant undergo investigation or receive treatment for this disease condition or injury in the past year O No O Unknown O Yes please explain and identify provider if known b Since the accident has the applicant developed any other disease condition or injury not related to the automobile accident that could affect his her response to treatment for the injuries identified in Part 6 O No O Unknown O Yes please explain Send any attachments directly to the insurer a Part 8 a Does the applicant s impairment s from the injuries identified in Part 6 affect his her ability to carry out Activit iaar SER His her tasks of employment O Not employed O No O Unknown O Yes His her activities of normal life O No O Unknown O Yes b If Yes to either of the questions above briefly describe the activities limited by the impairment and their impacts on the applicant s ability to function c Ifthe applicant is unable to carry out pre accident employment activity is the employer able to provide suitable modified employment to the applicant O Not employed O Yes O Unknown O No please explain Effective date 2012 11 01 PRINT RESET SAVE OCF 18 FSCO 1207E 1 Page 3 of 5 Queen s Printer for Ontario 2012 Part 9 Plan Goals Outcome Evaluation Methods and Barriers to Recovery Part 10 Signature of Applicant Must be completed un
10. one by deceit falsehood or other dishonest act to defraud or attempt to defraud an insurance company Name of Applicant or Substitute Decision Maker please print Signature of Applicant or Substitute Decision Maker Date YYYYMMDD OCF 18 Page 4 of 5 Queen s Printer for Ontario 2012 Applicant Name Policy Number OCF 18 Provider Name Claim Number INSURER FAX BACK Provider Fax Date of Accident P Provider Regulated Unregulated Provider Hourly Rate Part 11 Referenca tprovider Type Last Name First Name College Registration AISI Number if it applicable Health Care Number applicable or blank Providers B Cc D E F NT aN aaan SS Provider Estimated Projected Part 12 G S Ref Description tCode tAttribute Ref Quantit t Cost Total Total Proposed Y Measure Count Cost Goods or 1 Services Requiring 2 Insurer Approval 3 4 To the extent possible this 5 Treatment and Assessment Plan 6 should include all goods and services G S 7 contemplated by the Regulated 8 Health Professional 9 referred to in Part 5 for the period of this Treatment 10 and Assessment Plan 11 12 13 Estimated duration of this Plan Weeks Sub Total How many visits have you already provided visits Minus MOH Note t Refer to the User Manual coding guidelines posted at www hcaiinfo ca Minus Other Insurer 1 2 A i i TAX if applicable Attributes codes are used to furth
11. reatment and Assessment Plan has been reviewed with the applicant by the regulated health professional in Part 5 and the goods and services contemplated are reasonable and necessary for the treatment and rehabilitation of the applicant for the injuries identified in Part 6 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 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 Health Practitioner please print Signature of Health Practitioner Date YYYYMMDD Name of Regulated Health Professional College Registration Number You are a Chiropractor Dentist Facility Name if applicable AISI Facility Number if applicable Massage Therapist Nurse Address Occupational Therapist Optometrist Physician City Province Postal Code Physiotherapist Psychologist Telephone Number Extension Eax Number Speech Language Pathologist Social Worker Other OOUOOOOOOOOOO Email Address CONFIR
12. t Name Policy Holder First Name same as Applicant O OR SEES Part 3 OTHER INSURANCE Is there other insurance coverage for any goods and services listed in this Treatment and Assessment Plan Other have made reasonable enquiries of the applicant and have determined that Insurance O NO There is no other insurance coverage identified for these O YES There is other insurance coverage that is potentially available Information goods and services 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 To be completed Yes No Not applicable by the regulated E PP health Other Insurer Name Other Insurance Plan Or Policy Number professional referred to in Part Pat r 5 with information 1 Name of Plan Member Other Insurer s Identifier from the applicant Other Insurer Name Other Insurance Plan Or Policy Number Other nearer Name of Plan Member Other Insurer s Identifier FSCO 1207E 1 PRINT RESET SAVE Page 1 of 5 Queen s Printer for Ontario 2012 Part 4 Signature of Health Practitioner Treatment and Assessment Plan Certification Part 5 Signature of Regulated Health Professional Treatment and Assessment Plan Preparation and Supervision If same person as Part 4 check here L and DO NOT COMPLETE Part 5 Name of Health Practitioner College Registration Number You are
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