Rapport du chiropraticien sur l’évolution du patient
Chiropractor's progress/discharge report.
- Completed by
- Chiropractor
- Issued by
- WCB Manitoba
- Format
- Fillable PDF
- Language
- English
WCB Manitoba Chiropractor First Report (4C)
A Manitoba chiropractor files this one-page report after first assessing a worker injured on the job. The WCB uses it to place the case in one of six guideline categories, spinal or extremity injuries that are predominantly symptomatic, involve significant loss of mobility or are complicated, which sets the expected treatment duration. It also records the treatment plan, exercise program and work abilities.
Who completes it
The treating chiropractor completes and signs the whole form, including the worker's height, weight, PHIN and job title, the employer, and the worker's own description of the incident. There is no section for the worker or employer to sign.
Submitting and payment
- How to submit it
- Fax the completed fillable PDF to the WCB at the number printed on the form. WCB Manitoba directs all claim-related reports and billing forms to its fax line and asks that the claim number be included if available.
- Who pays
- WCB Manitoba pays the chiropractic initial report fee under service code 3019, a guaranteed expense paid whether the claim ends up unadjudicated, accepted or disallowed.
Good to know
- Report loss of mobility and complicating factors, such as age over 55 or multiple injuries to the same site; if you don't, the WCB assumes they are not present.
- The WCB does not approve daily treatment after the first week, expects three or fewer treatments a week after that, and two or fewer beyond the eighth week.
- A multisite request for a second, separate area of injury needs WCB pre-approval; conjoined spinal areas are treated as one area.
- The exercise program section supports the one-time exercise tariff (0019), which needs a documented program based on the Canadian Chiropractic Guidelines exercise module or equivalent.
Get the official form
Download the current version from the source each time; forms change without notice.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
How long will WCB Manitoba pay for chiropractic treatment?
It depends on the category. For spinal injuries, manipulation generally runs up to three weeks if predominantly symptomatic, six weeks with significant loss of mobility and ten weeks with complicating factors, with totals of four, eight and fourteen weeks when active rehabilitation is added. Extremity injuries have shorter limits.
How do I ask for chiropractic treatment beyond the guideline maximum?
Submit a written request explaining the rationale no later than two weeks before the maximum treatment duration for the case. The WCB tells the worker and chiropractor the expected maximum once the case is categorized, gives two weeks' notice before coverage ends, and decides extension requests within one week of receipt.
Is the Chiropractor First Report available in French?
The English form prints Aussi disponible en français, meaning it is also available in French, and its French title is Premier rapport du chiropraticien. The 4C printed beside the claim number box identifies it as the chiropractor's first report, while the progress report carries 7C.