Care Provider Forms & Fact Sheets 2018-12-17T15:07:53+00:00

Care Provider Forms & Fact Sheets

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Form Name Last modified
General
Accreditation Request – Primary level services 2017-Nov-15
Accreditation Request – To add assessment team member 2016-Feb-11
Accreditation Request – To add treatment team member 2016-Feb-11
Client health questionnaire 2015-Jul-31
Direct Deposit Application 2016-Jul-08
Functional examination record 2015-Jul-31
International health care provider report (CR) 2016-Oct-04
Job Information Worksheet (JIW) 2018-Sep-10
Lower extremity functional scale (LEFS) 2016-May-6
Neck disability index (NDI) 2016-Oct-04
Notification of Intake for Secondary or Tertiary Treatment Program (MCARETX) 2018-Mar-27
Practitioner’s Return to Work (PRTW)
See also: PRTW User Manual
2018-Nov-21
Roland Morris for backs 2015-Jul-31
QuickDASH 2015-Jul-31
Miscellaneous Billing Form (MISC) 2018-May-7
Audiology
Request for funding for new or replacement hearing aids (MCARE) 2018-Aug-31
Hearing Loss Questionnaire 2018-Sep-10
Audiology’s Billing Form (AUD) 2018-May-7
Chiropractor
Chiropractor’s Initial Report (CHI)
See also: CHI User Manual
2018-Sep-10
Chiropractor’s Progress/Discharge Report (CHP)
See also: CHP User Manual
2018-Sep-10
Practitioner’s Return to Work (PRTW)
See also: PRTW User Manual
2018-Nov-21
Chiropractor’s Billing Form (CHRO) 2018-May-7
Enabling Certificate for Medical Review Panel Examination (ECMRP) 2017-Sep-5
Dentistry
Dentist’s Initial Report (M7) 2018-Sep-10
Exercise Therapy
Primary Authorization to Treat – Exercise 2018-Jan-31
Practitioner’s Initial Assessment (TXI) 2018-Dec-03
Practitioner’s Progress Report (TXP) 2018-Dec-03
Practitioner’s Discharge Summary (TXD) 2018-Dec-03
Massage Therapy
Accreditation Request – Primary Level Service 2017-Nov-15
Primary Level Authorization to Treat – Massage Therapy (MCARE) 2018-Jan-31
Practitioner’s Initial Assessment (TXI) 2018-Dec-03
Practitioner’s Progress Report (TXP) 2018-Dec-03
Practitioner’s Discharge Summary (TXD) 2018-Dec-03
Therapist’s Billing Form (THER) 2018-May-7
Occupational Therapy
Occupational Therapist’s Initial Report (OTI) 2015-Jun-01
Occupational Therapist’s Progress/Discharge Report (OTP) 2015-Jun-01
Primary Level Authorization to Treat – Occupational Therapy 2018-Jan-31
Physiotherapist’s Billing Form (PHYS) 2018-Nov-21
Hospitals
Hospital’s Billing Form (HOSP) 2018-May-7
Hospital Admission/Discharge Record 2012-Aug-23
Pharmacy
Pharmacy’s Billing Form (DRUG) 2018-May-7
Physical Therapy
Physiotherapist’s Initial Report (PTI)
See also: PTI User Manual
2018-Sep-10
Physiotherapist’s Progress/Discharge Report (PTP)
See also: PTP User Manual
2018-Sep-10
Practitioner’s Return to Work Report (PRTW)
See also: PRTW User Manual
2018-Mar-27
Physiotherapist’s Billing Form (PHYS) 2018-Nov-21
Physicians
Physician’s Initial Report (PPI) 2018-May-1
Physician’s Progress/Discharge Report (PPP) 2018-May-1
Practitioner’s Return to Work Report (PRTW)
See also: PRTW User Manual
2018-Nov-21
Enabling Certificate for Medical Review Panel Examination (ECMRP) 2017-Sep-5
Physician’s Billing Form (DOC)  2018-May-7
Psychology/Counselling
Initial Assessment (PSYI) 2017-Jan-9
Progress/Discharge Report (PSYP) 2016-Jul-20
List of Restrictions 2016-Oct-04
Primary Level Authorization to Treat – Psychology & Occupational Therapy (MCARE) 2018-Jan-31

 

Fact Sheets & Publications

 

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