Family physician's first report after the initial assessment when injuries did not cause missed work/school or significant impairment of daily living.
- Completed by
- Family physician
- Issued by
- ICBC
- Format
- Fillable PDF
- Language
- English
ICBC CL489A: Family Physician Extended Medical Report
Family physicians complete this ICBC report after the first assessment of a crash-injured patient who has missed or modified work, school or training, or whose daily living is significantly impaired. Besides diagnosis and care plan, it records disability dates, duties the patient cannot perform and support for a graduated return to work. ICBC uses it to plan recovery and inform benefits, and it doubles as the invoice.
Who completes it
The family physician, ideally the patient's primary care provider, completes every part, including the certification and the consent selection. The patient consents to its release, or ICBC requests the report in writing with a CL491 letter.
How to fill it in
Invoice information
This block turns the report into ICBC's invoice: claim number, date of crash, date of the FP report, your ICBC vendor number, an invoice or reference number, and payee name and address. Dates use the dd/mmm/yyyy format. ICBC will not pay if the claim number, accident date, payee name and address, patient name or report date are missing.
Patient information, Physician information and Subjective (optional)
Enter the patient's first and last name, date of birth, Personal Health Number and whether an interpreter is required. In the physician block, give your name and MSP/practitioner number and say whether you are the patient's regular physician; ICBC prefers that the primary care provider complete the report. The key subjective complaints box is optional.
Relevant pre-crash history (questions 1 to 3)
Question 1 asks whether the patient ever had symptoms, treatment or medication for the injured areas before the crash; question 2, whether non-crash conditions contribute to the current diagnosis or symptoms. For each Yes, describe the condition and its possible impact on recovery. Question 3 asks about crash-related investigations or referrals to physicians providing specialized services.
Vocational status (questions 4 to 7)
Tick the patient's activities (full time, part time, self-employed, seasonal, training or apprenticeship, student, retired, homemaker or caregiver, not employed) and job position. Question 5 records absence from work, training, school or homemaking due to the crash. If the patient is still working, studying, training or caregiving, questions 6 and 7 record whether duties and hours are full or modified.
Vocational status (questions 8 to 13): off work or on modified hours or duties
Complete this part if the patient is off work or working modified hours or duties. Say whether they can perform all regular duties at regular hours; if not, list the specific duties or physical demands they cannot perform and the degree of impact. Give the disability start date and anticipated end date, whether you support a graduated return to work with its earliest start date and duration in weeks, and any specialized services or adaptive equipment needed.
Avocational status (questions 14 to 16)
Describe activities of daily living and other non-work activities. Question 15 asks whether the patient is currently unable to do pre-crash avocational activities and the earliest date they could return. Question 16 records regular or modified duties and hours in those activities, with your reasoning and recommendations if modified.
Assessment: Primary diagnosis and Other diagnosis
List the most serious or significant injury first, then all other diagnoses caused by or related to the crash. For each, choose nature of injury, body part and orientation, and add the ICD-9 code from the drop-down or the common-code appendix on page 5, using the comments box for detail or for codes not in the list.
Key Objective Findings (optional), Medical restrictions and/or limitations (questions 17 and 18), Barriers to recovery
Physical exam findings and key objective complaints are optional. Question 17 asks you to describe the medical restrictions or limitations and question 18 whether they are temporary or permanent, with details. The barriers box captures functional, physical, psychosocial, employer, medical or compliance factors that may slow the patient's recovery.
Recommended Care Management Plan and Prognosis and recovery timelines (questions 19 to 23)
Recommend treatments, investigations or referrals for the crash injuries. Question 20 asks whether you expect a return to pre-crash function with this plan (yes, no or unable to determine, with comments unless yes), and question 21 whether therapy beyond the plan is likely. Questions 22 and 23 ask for the prognosis and anticipated recovery timelines.
Treatment notes (questions 24 to 26), Additional comments and certification
Say whether medication was prescribed for the injuries and which, then give the anticipated date of full recovery and the anticipated treatment reassessment date. Add comments, tick the certification that the information is true and correct, and select either patient consent or an ICBC request under section 28 or 28.1 of the Insurance (Vehicle) Act.
Common mistakes
- Choosing CL489A when the patient is fully working or studying with no reduction; ICBC reserves it for missed or modified work, school or training, or significant impairment of daily living.
- Skipping questions 8 to 13 for a patient who is off work or on modified hours or duties; the form directs you to complete them.
- Leaving out the claim number, accident date, payee name and address, patient name or report date, any of which prevents ICBC from paying.
- Releasing the report without patient consent or an ICBC request letter, or leaving both consent statements unticked at the end.
- Locking the PDF before it is complete. After the Lock button is selected, the form can no longer be edited.
Submitting and payment
- How to submit it
- Send it to ICBC by fax or mail, from an EMR with the integrated ICBC template, or through ICBC's online submission tool for physicians. ICBC asks for reports within 30 days of the assessment date.
- Who pays
- ICBC pays the physician under fee code A94565, with the completed report serving as the invoice, and later visits without a report are billed to MSP through Teleplan.
Good to know
- Use CL489A rather than the Standard report (CL489) when the patient is not able to complete work, training or studying activities, and complete only one of the two after the initial assessment.
- Questions 8 to 13 apply when the patient is off work or on modified hours or duties: duties they cannot perform, disability start and anticipated end dates, graduated return to work and adaptive equipment.
- The report needs the ICBC claim number, which you get from the patient or ICBC. ICBC does not prepay reports or pay for missed or cancelled appointments.
- If the patient later stops recovering as expected and the care plan or diagnosis needs updating, the next report is the FP Reassessment Medical Report (CL489B).
Get the official form
Download the current version from the source each time; forms change without notice.
Family Physician (FP) Extended Medical Report
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.
Sources for this guide
- partners.icbc.com/health-services/physicians
- partners.icbc.com/assets/7KhbQynQf8sOcKzexyJlp5/CL489A-fp-extended-medical-report.pdf
- partners.icbc.com/assets/3NtyNGCanx0q2p697h627a/family-physician-quick-guide.pdf
- partners.icbc.com/assets/5bPXoL2I9uEexT4pgL5XMs/patient-consent-considerations-physicians.pdf
- partners.icbc.com/health-services/invoicing-reporting
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
What is the difference between ICBC CL489 and CL489A?
Both are the family physician's first report after a crash. CL489 is for patients who can fully complete work, training or studies with no absence or reduction. CL489A is for patients who missed or modified work, school or training, or have significant impairment of daily living, and it adds questions on disability dates, job demands, graduated return to work and adaptive equipment.
What return-to-work details does CL489A ask for?
If the patient is off work or on modified hours or duties, question 8 asks whether they can perform all regular duties at regular hours. Questions 9 to 13 cover duties or physical demands they cannot perform and the degree of impact, disability start and anticipated end dates, graduated return to work with start date and duration, and any adaptive equipment needed.
How do I get paid for CL489A?
The report is the invoice. Complete the claim number, vendor number, payee details and your invoice or reference number, then send it by fax, mail, integrated EMR or ICBC's online submission tool within 30 days of the assessment. ICBC pays under fee code A94565. Follow-up visits without a report are billed through MSP Teleplan using standard visit codes.
Do I need the patient's consent before sending CL489A?
ICBC's guidance for physicians says to explain the report's purpose and obtain consent before sending it, unless ICBC has issued a formal request letter (usually a CL491). At the end of the form you tick either the consent statement or the statement that the report responds to an ICBC request under section 28 or 28.1 of the Insurance (Vehicle) Act.