CNESST 5055: Compte de soins, physio ou ergothérapie

Clinics bill CNESST on this form for physiotherapy or occupational therapy given to an injured worker, and it doubles as the attendance record. It is sent twice: within 7 days of the initial evaluation, and again at the end of treatment with the end date filled in. Services must be billed within 180 days, and IVAC uses the same form for crime victims.

Who completes it

The clinic's physiotherapist, physiotherapy technologist (T.R.P.) or occupational therapist completes the whole form. The treating professional's prescription goes with it, and the clinical reports are the Rapport de physiothérapie (5053) or Rapport d'ergothérapie (5054).

Submitting and payment

How to submit it
Send it through CNESST-certified clinic software, CNESST's Envoi de document service or by fax, within 7 days of the initial evaluation and again when treatment ends. Bill within 180 days of the service.
Who pays
CNESST pays the clinic at its published tariff, with separate rates for the initial evaluation, treatment by a physiotherapist, OT or T.R.P., home physiotherapy and reports.

Good to know

  • If no treatment is needed after the evaluation, enter the initial evaluation date as the end date.
  • The same form serves as both invoice and attendance record, for CNESST work injury files and for IVAC crime victim files.
  • CNESST's tariff pays a different initial evaluation rate for physiotherapy and for occupational therapy, and a different treatment rate for a T.R.P. than for a physiotherapist or OT.
  • The current version is dated 2023-06; it is a fillable PDF with 135 fields, published in French only.

Get the official form

Download the current version from the source each time; forms change without notice.

Compte de soins et traitements de physiothérapie ou d'ergothérapie

Statement of Account for Physiotherapy or Occupational Therapy Care and Treatment

Fill it with Vero

Upload the fillable PDF 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.

How this list is checked

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.

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Frequently asked questions

When do I send CNESST form 5055?

Twice. First within 7 days of the initial evaluation, then at the end of treatment with the end date entered. If the evaluation shows no treatment is needed, enter the initial evaluation date as the end date. Every service must be billed to CNESST within 180 days.

Who can complete CNESST form 5055?

The clinic's physiotherapist, physiotherapy technologist (T.R.P.) or occupational therapist. CNESST's tariff sets different rates depending on who gives the care: initial evaluations differ for physiotherapy and occupational therapy, and treatments by a T.R.P. are paid at a different rate from those by a physiotherapist or OT.

Does IVAC use CNESST form 5055?

Yes. IVAC, the crime victims compensation program CNESST administers, uses the same Compte de soins et traitements de physiothérapie ou d'ergothérapie, which serves as both invoice and attendance record. The physiotherapy (5053) and occupational therapy (5054) reports are also shared with IVAC files.