When a car accident injury is predominantly a minor injury, such as a sprain, strain or whiplash associated disorder, the initiating health practitioner uses this form to start pre-approved treatment under FSRA's Minor Injury Guideline (MIG). It is completed at the initial visit and submitted within 10 business days, and the insurer must confirm within five business days whether the patient is an insured person.
The initiating health practitioner (chiropractor, dentist, nurse practitioner, occupational therapist, physician or physiotherapist) completes every part except Part 9, which the applicant signs, and Part 11, which the insurer completes. The applicant supplies the information for Parts 1 to 3 and initials Part 8 when assigning direct payment.
The applicant supplies identity, insurer and policy holder details. Enter the claim number, policy number or both, and copy the date of birth, gender and accident date exactly, because HCAI matches the form to the claim on those five elements. In HCAI, choose the licensed insurer rather than an independent adjusting firm, and enter the policy holder's last name when the applicant is not the policy holder, such as a child on a parent's policy.
You complete this part with information from the applicant. Confirm your reasonable enquiries about other coverage for the guideline services, list up to two other insurers and state whether Ministry of Health coverage applies. For accidents in Ontario on or after July 1, 2026, the auto insurer must pay medical and rehabilitation expenses even where a supplementary health plan would cover them; medication expenses are the exception.
Signed by the practitioner who is authorized to treat the impairment and will be responsible for the guideline services. In HCAI that must be a chiropractor, dentist, nurse practitioner, occupational therapist, physician or physiotherapist associated with your facility, and external practitioners cannot sign. Tick the box if you are not the first initiating practitioner. Signing certifies the treatment follows the Minor Injury Guideline and that you reviewed it with the applicant; print the form, sign it and keep it on file.
Based on your most recent examination, list injuries and sequelae that are a direct result of the accident with ICD-10-CA codes, most significant first and each code once, even if several practitioners are involved. HCAI's common categories are S codes for a single injury, T codes for multiple or bilateral injuries, F codes for mental and behavioural conditions and R codes for symptoms and abnormal findings. HCAI staff cannot advise on coding, so ask your professional association.
Record whether the applicant was employed at the time of the accident and whether a pre-accident disease, condition or injury could affect their response to treatment (No, Unknown or Yes with an explanation). If Yes, say whether it was investigated or treated in the past year, naming the provider if known. HCAI's coding guidance puts prior conditions here rather than among the Part 5 injury codes.
Answer whether you have identified barriers to recovery that may affect the success of treatment for this applicant, and explain any Yes. The MIG expects the initial visit to review functional status and psychosocial risk factors, such as changes in function and other barriers to recovery, without a formal psychological assessment. The form refers you to the HCAI user manual for help identifying barriers.
The applicant's initials direct the insurer, including the Motor Vehicle Accident Claims Fund, to pay your facility directly for the approved guideline services. This is allowed only if the facility holds a valid service provider licence at the time of treatment and invoicing; otherwise select No in HCAI, because the applicant's consent cannot override the licensing rule. Have the applicant initial the printed copy and keep it on file.
After you review the treatment with the applicant or substitute decision maker, they sign to confirm they agree with it and consent to information sharing with the insurer. If you are not the first initiating practitioner, the signature also lets the insurer contact the first one to find out how much guideline treatment has been used. HCAI will not submit the form without a signature on file or an insurer waiver.
The Minor Injury Guideline is the only guideline listed. Enter its estimated fee, any supplementary goods and services, and other pre-approved services such as x-rays with the number of views. Under the MIG, x-rays need no insurer approval only in set circumstances, for example a suspected bony injury, and only when no comparable x-rays were taken since the accident. HCAI warns when a line exceeds its maximum, and insurers may not pay the excess.
The adjuster confirms whether the policy was in force at the time of the accident and marks Approve or Do not approve, with an explanation to follow or attached. The adjuster can also waive the applicant's signature here. The insurer must acknowledge the form within five business days, and in HCAI a Responded status on an OCF-23 means the patient has a valid policy in force.
Download the current version from the source each time; forms change without notice.
Treatment Confirmation Form
Formulaire de confirmation pré-approuvé du traitement de la structure
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.
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
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A sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation, and any clinically associated sequelae, when the impairment is predominantly a minor injury. A whiplash associated disorder has no objective, clinically relevant neurological signs and no fracture or dislocation of the spine. Sprains and strains include partial tears but not complete tears, and a subluxation is a partial dislocation.
The MIG requires it within 10 business days of the initial visit, unless the insurer has waived it. Within five business days of receiving it, the insurer must acknowledge receipt and say whether the patient is an insured person; in HCAI this shows as a Responded status. Once the insurer accepts the claim, it pays invoices for MIG services within 30 days.
A health practitioner who is authorized by law to treat the impairment, authorized under the MIG to complete the form and responsible for providing the services. HCAI accepts a chiropractor, dentist, nurse practitioner, occupational therapist, physician or physiotherapist associated with the submitting facility. External practitioners cannot sign, and the form cannot be submitted without the signature on file.
The new practitioner informs the insurer, which says what MIG services were already provided, and an amended OCF-23 is submitted with the box ticked for not being the first initiating practitioner. The previous practitioner bills 25% of the block for each week or part week of treatment given, and the insurer pays the new one only for services not yet provided.