Doctor of Chiropractic Report
Flat Fee Program


Report

* required  
Report Type Initial Report
(received by ICBC within 5 calendar days of initial visit by patient, along with signed Treatment Confirmation and Consent Form)
Discharge Report  *
Status employment / pre-accident level
not employed / capable of pre-accident level
employment / capable of modified level
not employed / capable of modified level
further investigation / treatment
non compliance / non attendance
condition improving (explain)
no relevant clinical improvement (explain)  *
Explain *
Date of Discharge  (dd-mmm-yyyy) *
How much, has condition improved since the injury?
None Limited Some Much  *
If you had submitted an extension request for this patient,
was it approved? Yes No Not applicable  *

Claim Information

 
Claim Number  *
Name of Adjuster *
Date of Injury  (dd-mmm-yyyy) *
Would you like to consult with the adjuster regarding the patient's clinical circumstances and other possible treatment options?
Yes No *
Do you support the patient's assessment in a Disability Management Program to determine other services to support their recovery?
Yes No *

Patient Information

 
Name of Patient
(last, first, middle)
*
Gender  *
Birthdate  (dd-mmm-yyyy) *
Personal Health Number *
Date of First Visit  (dd-mmm-yyyy) *
Number of Visits to Date *
Is patient receiving concurrent treatment?
Yes No *
Treatment MassagePhysioOther (describe) *
Describe *

Clinical Information

Outcome Measures Score
Oswestry Disability Index *
Neck Disability Index *

History

Are you the patient's regular chiropractor? *
Yes No *
On what date did you first treat this patient  (dd-mmm-yyyy) *
Are there pre-existing or other problems affecting the patient's injury, recovery and disability?
Yes No *
Describe *
If there are pre-existing or other problems affecting the patient's injury, recovery or disability, did these restrict the patient from returning to work / returning to normal function?
Yes No *
For how long?  *

Current Diagnosis and Treatment

What is your diagnosis?
(Describe, including WAD classification, if applicable)
 
 *
What are patient's subjective symptoms?  
 *
List all X-rays and other investigations  
 *
List all consultations with other providers (including their names)  
 *
Treatment types, techniques and modalities used, their frequency and duration  
 *
Dates of all visits  
 *

Return to work / Return to function

From date of injury or last report, has the patient:
• been off work? Yes No *
Give date(s) *
• been off work as a result of this injury? Yes No *
Give date(s) *
In your opinion, is the patient now able to return to work / return to
normal function? Yes No *
If no, what are the current conditions restricting the patient from returning to work / returning to function?      
*
In your opinion, is it likely the patient will return to pre-accident status from the injuries related to this claim?
Yes No *
Please describe *
Estimated date
of maximum chiropractic recovery
(full recovery or best possible recovery?)
 (dd-mmm-yyyy) *
Occupation / regular duties *
In your opinion, the patient is able to do the following
Full timeModified duties
Full dutiesunable to work at any job *
Part time 
If able to work modified duties, please describe 
Is patient able to maintain usual activities?
Yes No *
If no, what are current limitations and what activities are the patient unable to do?
*     

Contact Information

 
Chiropractor Name *
Supplier Number *
Practitioner Number *
Address *
Phone Number  *
Email Address *
Date  (dd-mmm-yyyy) *
Reminder:ICBC must receive a signed Treatment Consent Form either by email (chiropractic@icbc.com) or fax (604-647-6148). Please include in the subject line the customer's name and claim number.

Personal information provided on this form is collected pursuant to s. 26 of the Freedom of Information and Protection of Privacy Act. The personal information will be used for the purposes of claims handling.

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CL470 (102015)