Referral Form - Ontario Auto

Date:

REFERRAL SOURCE


*First Name


*Last Name


*Phone #

Ext.

*Fax #


*Email




*Company


Assistant


*Address


*City


*Province


*Postal Code

PRIMARY SOURCE (if applicable)


Name


Company


Address


City


Province


Postal Code

CLAIMANT INFORMATION


*First Name


*Last Name


Address


City


Province


Postal Code


Gender

Male Female

Claim #


Date of Birth
(mm/dd/yyyy)

/ /

Date of Loss
(mm/dd/yyyy)

/ /

Primary Phone #




Alternate Contact


Phone #


Lawyer Name


Phone #


Physician Name


Phone #


Employer Name


Phone #

INJURY DETAILS


Nature of Injury

Soft Tissue Orthopaedic Psychological Neurological Spinal Cord
Other

Injury Reference Code


Injury Details

ANCILLARY SERVICES


Interpreter Required

Yes No

Transportation Required

Yes No

Language


Other

ASSESSMENT INFORMATION

Date of OCF 18/22 in Question Details
Reason and Description of the Examination The examination is a paper review only in accordance with the SABS
We request an in person examination
This is a rescheduled examination
Assessment Type Determination of Catastrophic Impairment - Paper Review (OCF 9)
Paper File Review - OCF 18
Paper File Review - OCF 22
Report Due
In Person Assessment - OCF 18
Pre-Claim Examination
Not Applicable
Specified Benefit Review (check below as applicable)


Benefit Category
Income Replacement
Employed
Unemployed
Post-104
Attendant Care
Caregiver
Non Earner
Other
Medical and Rehabilitation
Housekeeping & Home Maintenance

ASSESSMENT(S) REQUIRED

Chiropractic
Dental/Oral
Form 1
FAE
In-Home Assessment
Neuropsychological
Neurological
Orthopaedic
Psychiatric
Psychological
Psycho-Vocational
Physiatry
Physiotherapy
Physical Demands Analysis
TSA
Labour Market Survey
Vocational Testing
Worksite Assessment
Vocational Assessment (please specify)
     TSA Labour Market Survey Vocational Testing  

Other Ax
Executive Summary of Multi-Disciplinary Assessment Opinions

Timeframe for Scheduling of Assessment
Assessment Confirmation to be sent by Email Fax
Claimant Confirmation Letter required Yes No      Timeframe
Medical File to be forwarded Complete Medical Documentation
Updated Medical Documentation Since Last Referral
Comments / Special Instructions
File 1: + Add

File 2: + Add
File 3: + Add
File 4: + Add
File 5: + Add
File 6: + Add
File 7: + Add
File 8: + Add
File 9: + Add
File 10: