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ClaimSecure Nursing Care Assessment (2002000-022A-CL)

ClaimSecure uses this assessment to pre-approve private nursing care under a plan member's benefits. The claimant reports any provincial home care hours already approved, the nursing agency or facility lists its rates, and the physician explains why nursing care is needed, at what level and for how long. ClaimSecure then notifies the claimant in writing about plan coverage.

Who completes it

The physician completes Part 3 (current medical information) in full, with signature and stamp. The claimant completes Parts 1, 2 and 2A and the privacy consent, and the nursing agency or facility completes Part 2B.

Submitting and payment

How to submit it
The completed form is returned to ClaimSecure with supporting documentation by mail, fax or email; ClaimSecure lists it with the specialized forms to submit with an estimate before approval.

Good to know

  • Part 3 asks whether the condition is acute, chronic or palliative and stable or unstable, and whether RN or RPN/LPN care is recommended.
  • State the reason nursing care is required and the specific functions involved, how long it is needed, and whether it is delivered in home or out of home.
  • The claimant reports provincial home care already approved, including RN, LPN/RPN and PSW hours per day and days per week, and the case manager's name.
  • All nursing care providers must be licensed and in good standing in the province where they practise.

Get the official form

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

Nursing Care Assessment Form

Official pagePDF

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.

See how Vero Documents works

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What does the physician complete on the ClaimSecure nursing care assessment?

Part 3: diagnosis, history of the medical condition, prognosis, the reason nursing care is required and its specific functions, whether the condition is acute, chronic or palliative and stable or unstable, the recommended level of care (RN or RPN/LPN), how long care is needed and whether it is in or out of home.

Does ClaimSecure need provincial home care information first?

Part 2 asks whether the claimant has contacted the provincial plan. If so, Part 2A records the dates of the nursing assessment and next assessment and the RN, LPN/RPN and PSW hours approved by the province; if not, the claimant must explain why.

Who can provide the nursing care ClaimSecure pre-approves?

The form states that all nursing care providers must be licensed and in good standing in the province where they practise. The nursing agency or facility completes Part 2B with its name, hourly rates for RN, LPN/RPN and PSW care, and the proposed start date.