Download Disability Certificate Application Form

Disability Certificate (OCF-3)Use this form for accidents that occur on or after November 1, 1996. Claim Number: Policy Number: Date of Accident: (YYYYMMDD) For this applicant, this is Disability Certificate number _______ from this health professional/facility Use this form for accidents that occur on or after November 1, 1996. If your insurance company asks you to complete this form, fill out Parts 1 to 3 and give the form to your health practitioner (chiropractor, dentist, nurse practitioner, occupational therapist, optometrist, physician, physiotherapist, psychologist, speech language pathologist). After your health practitioner has explained your accident-related injury to you, sign Part 4. Your health practitioner will complete the rest of the form, based on his/her most recent assessment, and return it to the insurance company. If this disability certificate is being completed to support your application for accident benefits, it must be completed by your health practitioner no earlier than 10 business days of the date of your application. If your insurer has requested a new disability certificate, it must be provided within 15 business days of this request. Only an authorized health practitioner can complete this form. The health practitioner's opinion will be relied upon by people who review the certificate to make important decisions. Accordingly, it is necessary to be accurate and complete. Please print clearly and provide all information requested. This form may not be materially altered. Confidentiality: Collection, use and disclosure of this information is subject to all applicable privacy legislation. Part 1 Applicant Information To be completed by the applicant Date Of Birth (YYYYMMDD) Gender Male Female Telephone Number Extension Last Name First Name Middle Name Address City Province Postal Code Part 2 Insurance Company Information To be completed by the applicant Name of Insurance Company City or Town of Branch Office (if applicable) Name of Insurance Company Representative Telephone Fax Name of policy holder same as: Applicant OR Policy Holder Last Name Policy Holder First Name Part 3 Accident Description Give a brief description of the accident and what happened to you. Please describe any injuries you sustained as a direct result of the accident. To be completed by the applicant additional sheets attached Part 4 Applicant Signature I authorize my treating health professional to collect, use and disclose to my insurer or to a health professional, social worker, or rehabilitation expert properly identified by my insurer to conduct an examination, only such information relating to my health condition and treatment received as a result of the automobile accident and any pre-existing or subsequently occurring health conditions that may be barriers to my recovery as a result of the automobile accident, as is reasonably required for the purpose of providing treatment and determining my eligibility for benefits. I authorize the health practitioner who completes this form to contact my employer, if this is necessary, to confirm the essential tasks of my employment and the nature and extent of any available work with modified hours or duties. 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. Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision Maker Date (YYYYMMDD) To the Health Practitioner: Please complete the following information based on your most recent examination of the applicant named in Part 1 and return the form to the insurance company listed in Part 2. Please print clearly. Part 5 Injury and Sequelae Information This part and the rest of this form must be completed by your Health Practitioner Provide a description (list most significant first) and associated ICD-10-CA+ code for any injuries and sequelae that are the direct result of the automobile accident. Description Code Note+:Refer to the User manual at www.hcaiinfo.ca for ICD-10-CA coding information. Part 6 Relevant Dates Part 7 Disability Tests and Information a) Based on your current knowledge and information provided by the applicant, please provide a response to each Benefit/Applicant Category Benefit/Applicant Category Disability Test Onset of Disability (YYYYMMDD) Task/Activity Limitations Anticipated Duration Income Replacement Benefits Employed: working at the time of the accident Is the applicant substantially unable to perform the essential tasks of his/her employment at the time of the accident as a result of and within 104 weeks of the accident? Yes No N/A Please explain: 1-4 weeks 5-8 weeks 9-12 weeks more than 12 weeks Can the applicant return to work on modified hours and/or duties? Yes No N/A Please explain: 1-4 weeks 5-8 weeks 9-12 weeks more than 12 weeks Unemployed: but worked 26 weeks during the 52 weeks before the accident Is the applicant substantially unable to perform the essential tasks of the employment held for most of the time during the 52 weeks before the accident? Yes No N/A Please explain: 1-4 weeks 5-8 weeks 9-12 weeks more than 12 weeks Non-Earner Benefits Does the applicant suffer a complete inability to carry on a normal life? (i.e., Has the applicant sustained an impairment that continuously prevents the person from engaging in substantially all of the activities in which the person ordinarily engaged before the accident?) Yes No N/A Please explain: 1-4 weeks 5-8 weeks 9-12 weeks more than 12 weeks Benefit/Applicant Category Disability Test Onset of Disability (YYYYMMDD) Task/Activity Limitations Anticipated Duration Caregiver Benefits As the Primary Caregiver, does the applicant suffer a substantial inability to engage in the caregiving activities in which he/she engaged at the time of the accident? (Primary Caregiver means that, at the time of the accident, the applicant was residing with a person in need of care and the applicant was the primary caregiver for the person in need of care and did not receive any remuneration for engaging in caregiver activities.) Yes No N/A Please explain: 1-4 weeks 5-8 weeks 9-12 weeks more than 12 weeks Lost Educational Expenses Is the applicant, as a result of the accident, unable to continue in an elementary, secondary, post­secondary or continuing education program that the applicant was enrolled in at the time of the accident? Yes No N/A Please explain: 1-4 weeks 5-8 weeks 9-12 weeks more than 12 weeks Housekeeping and Home Maintenance Expenses Does the applicant suffer a substantial inability to perform the housekeeping and home maintenance services that he/she normally performed before the accident? Yes No N/A Please explain: 1-4 weeks 5-8 weeks 9-12 weeks more than 12 weeks b) If you responded Anticipated Duration 'more than 12 weeks' to any disability test above, please explain why the task/activity limitations are likely to persist beyond 12 weeks. Part 8 Further Investigations or Consultations Part 9 Prior and Concurrent Conditions a) Have there been any examinations, investigations, or consultations not previously reported by you? No Yes (please specify findings and results) b) Are further examinations, investigations or consultations contemplated or required? No Yes (please specify) a) Prior to the accident, did the applicant have any disease, condition or injury that affected his/her ability to perform the activities listed in Part 7? No Unknown Yes (please explain) If yes, is the applicant currently receiving any disability benefits for the pre-existing disease, condition or injury? No Unknown Yes (please explain) If you treated the applicant for similar conditions prior to the accident, please describe (include date of onset, any subsequent interventions, and status at the time of the accident). b) Since the automobile accident, has the applicant developed any disease, condition or injury, not related to the accident, that could affect his/her disability? No Unknown Yes (please explain) Part 10 Medications a) Please list any medications (including dosage and frequency) that the applicant is currently taking for injuries related to the automobile accident. Were these medications prescribed by you? No Yes b) Please list any medications (including dosage and frequency) that the applicant is currently taking as a result of prior or concurrent conditions identified in Part 9. Were these medications prescribed by you? No Yes Part 11 Health Practitioner Signature Name of Health Practitioner College Registration Number You are a: Chiropractor Dentist Nurse Practitioner Occupational Therapist Optometrist Physician Physiotherapist Psychologist Speech-Language Pathologist Facility Name (if applicable) AISI Facility Number (if applicable) Address City Province Postal Code Telephone Number Extension Fax Number Email Address I confirm 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. Name of Health Practitioner (please print) Signature of Health Practitioner Date (YYYYMMDD) Note: The fee for completing this certificate 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.