Physiotherapy and occupational therapy clinics must complete this one-page CNESST form to get authorization to treat a worker with a recurrence, relapse or aggravation (récidive, rechute ou aggravation) of an employment injury. The clinic supplies its supplier number and the worker's details, and CNESST's Physio-Ergo team and regional office use the rest of the page to decide whether treatment is authorized.
The physiotherapy or occupational therapy clinic enters its supplier number and the worker block: name, health insurance number, site of injury, original event date, recurrence date, date the referral was received and date of the request. Everything under Réservé à la CNESST is completed by CNESST.
Download the current version from the source each time; forms change without notice.
Demande d'autorisation de traitement de physiothérapie – ergothérapie
Request for Treatment Authorization – Physiotherapy/Occupational Therapy
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
CNESST's page says you must complete it to obtain authorization to provide physiotherapy or occupational therapy treatment to a worker who has a recurrence, relapse or aggravation of an employment injury. The form asks for the original event date and the recurrence date, along with the site of injury and the date the referral was received.
Online through the Transmission d'un document section of cnesst.gouv.qc.ca/nous-joindre, or by fax. The form carries your supplier number, so CNESST's Physio-Ergo team can notify the establishment of the decision and, if the file is refused, send a standard letter, both dated on the form.
The regional office section lists the reasons it can tick: more information is needed, the relapse has not been declared, the file has been refused, authorization from the medical office is pending, or another reason it specifies. It can add remarks, and the officer signs and dates the decision.