Doctor of Chiropractic
Request to Extend Treatment
Flat Fee Program

As applicable, request to be submitted to ICBC prior to the end of the 10th week of chiropractic treatment.

Claim Information

* required

Claim Number	*
Name of Adjuster	*
Adjuster's Email Address	@icbc.com  *
Date of Injury	(dd-mmm-yyyy) *

Patient Information
Name of Patient (last, first, middle)	*
Gender	M F  *
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	Massage	Physio	Other (describe) *

Describe

*

Clinical Information
Outcome Measures Score
	Oswestry Disability Index	*
	Neck Disability Index	*

What is your diagnosis? (Describe, including WAD classification, if applicable)
	*
Description of treatment provided to date
	*

Has there been any relevant clinical improvement in condition?

	Yes No *

Please explain

*

How much has condition improved since the injury?
	No improvement	Some improvement
	Limited improvement	Much improvement *

Extenuating circumstances information

Explain why this patient has not yet reached maximum chiropractic improvement and/or what circumstances are preventing the patient for completing treatment within the alotted 14 week time frame?
	*
What objective clinical findings support extending chiropractic treatment?
	*

Are there other conditions affecting recovery?

Yes No *

Please explain

*

If you have attachments email them separately to chiropractic@icbc.com

Return to work / function

In your opinion, is patient expected to return to work / return to function following additional treatment?

Yes No Currently at work *

If no, what are the current conditions restricting the patient from returning to work / returning to function?
	*

If yes, or currently at work, please select all that apply:
	Full time	Part time
	Full duties	Modified duties *

If able to work modified duties, please describe

In your opinion, is it likely the patient will return to pre-accident status from the injuries related to this claim?

Yes No *

Estimated date of maximum chiropractic recovery (full recovery or best possible recovery?)	(dd-mmm-yyyy) *
Occupation / regular duties		*

Is patient able to maintain usual activities?

Yes No *

If no, what are current limitations and what activities is the patient unable to do?
	*

In your opinion, would it be beneficial for the patient to participate in a voluntary assessment in a Disability Management Program to determine what additional services may aid their recovery?

Yes No *

Contact Information
Chiropractor Name		*
Supplier Number		*
Practitioner Number		*
Address		*
Phone Number	*
Email Address		*
Date	(dd-mmm-yyyy) *

If the Chiropractor is submitting a Request to Extend Treatment, this form is to be sent to the ICBC adjuster. The ICBC adjuster is responsible for approving the Request to Extend Treatment. If the ICBC adjuster approves the Chiropractor's Request to Extend Treatment, the Chiropractor may then choose to request payment from ICBC Claims Services. To request payment for the extension of treatment before the Patient is discharged, the Chiropractor is required to submit a request to ICBC Claims Services, in writing, referencing the Patient's name and claim number to any of the points of contact indicated below. Note, if no request for payment of the Request to Extend Treatment is made before the Patient is discharged, Claims Services will make payment for approved Requests to Extend Treatment when the Discharge Report is submitted to Claims Services.

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.

For payment of approved Requests to Extend Treatment before the Patient is discharged, choose one of the following points of contact:
by fax: 604-647-6148
by email: chiropractic@icbc.com
by mail: ICBC Claims Services, 456 5th Avenue West, Vancouver BC  V5Y 3Z3

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.

				CL470A (072022)