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 Range of Motion Loss Report: Fee Code A94577
ICBC asks a practitioner to complete this report when it needs measurements of permanent range of motion loss in a specific joint or body area to assess permanent impairment. Physicians, chiropractors, kinesiologists, occupational therapists, physiotherapists and registered massage therapists can complete it, and ICBC funds it only when an ICBC Claims Contact has requested it.
Who completes it
The practitioner ICBC contacts completes the whole report on the template ICBC provides. ICBC's program guides say the Claims Contact reaches out when the report is needed for benefit administration.
Submitting and payment
- How to submit it
- Physicians send a separate invoice for each report showing the claim number, date of accident, payee name and address, patient name and report date. Recovery Network providers bill it in HCPIR or HCPP by selecting Range of Motion Report.
- Who pays
- Physicians bill fee code A94577, while chiropractors, kinesiologists, occupational therapists, physiotherapists and registered massage therapists receive the per-report fee in ICBC's Fee Schedule for Health Care Providers (CL534).
Good to know
- For chiropractors and kinesiologists, the measurement happens during a regularly scheduled treatment session, which can be invoiced separately from the report.
- Occupational therapists can invoice up to 30 minutes of assessment time separately, reflecting the complexity of the customer's situation.
- ICBC's OT program guide refers to the range of motion report as the CL737 series and bills it apart from miscellaneous form completion.
- A companion scarring measurement report covers permanent scars and has its own physician fee code, A94575.
Get the official form
Download the current version from the source each time; forms change without notice.
Range of motion loss report
Fill it with Vero
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.
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
Where do I get the ICBC range of motion report template?
ICBC supplies the template with its request, and the chiropractic, kinesiology and occupational therapy program guides also point to ICBC's Partners Page. Complete the report only after an ICBC Claims Contact asks for it, because ICBC funds it only in that case.
Can I bill the range of motion assessment separately from the report?
It depends on your profession. Chiropractors and kinesiologists assess during a regularly scheduled treatment session that can be invoiced separately, and occupational therapists may invoice up to 30 minutes of assessment time. Physicians bill the report under fee code A94577 with a separate invoice for each report.