Prescriber's request for an exemption from WCB's mandatory generic drug policy.
- Completed by
- Prescriber
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
WCB Nova Scotia Intake Report: Form A
Form A is the intake report a treating clinic sends WCB Nova Scotia when a worker starts tiered services, part of a May 2014 set with Forms B, C and E and an Additional Information sheet. It records worker, provider, employer and injury details and an initial job match based on what the worker reports, rating pre-injury demands and current capability from sedentary to very heavy.
Who completes it
The treating health care provider completes the form; the employer section should ideally be completed by the employer before referral, including the employer's signature, and otherwise by the provider. The form is copied to the employer, the physician and WCB.
Submitting and payment
- How to submit it
- Fax it to WCB with the worker's claim number on every page. WCB's current reporting page lists Forms B, C and E, not Form A, for approved out-of-province clinics.
- Who pays
- WCB guarantees payment only for services it has pre-authorized, and providers outside the Work-Connected Recovery network fax a separate invoice for each worker.
Good to know
- The employer section asks whether a WCB accident report has been filed, the firm and division numbers, the worker's job title, and whether job task information and transitional duties are available.
- Injury details include mechanism of injury, MDA diagnosis by body part, whether the injury prevents pre-injury work or transitional duties, any similar earlier problem, and the date of the initial visit.
- The initial job match is based on the worker's information and rates demands as sedentary, light, medium, heavy or very heavy, using WCB's Work Capabilities definitions.
- Providers in Nova Scotia's Work-Connected Recovery network deal with Lifemark for forms, reporting and invoicing and do not submit forms through WCB Online.
Get the official form
Download the current version from the source each time; forms change without notice.
Intake Report – Form A
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
Who completes the employer section of WCB Nova Scotia Form A?
Ideally the employer, before the worker is referred, including the employer's signature. If that is not possible, the health care provider completes it. The section covers the employer name and contact, whether a WCB accident report has been filed, firm and division numbers, the worker's job title and whether transitional duties are available.
Is Form A still used for WCB Nova Scotia tiered services?
The May 2014 form remains in WCB's resource library alongside Forms B, C and E. WCB's current reporting page lists only Forms B, C and E for approved out-of-province clinics, while in-province care for musculoskeletal and psychological injuries is delivered through the Work-Connected Recovery network, where Lifemark handles forms and reporting.
What does the job match summary on Form A mean?
It compares the worker's pre-injury job requirements with present work capability and any transitional duties, each rated sedentary, light, medium, heavy or very heavy using WCB's Work Capabilities definitions. On Form A it is based on information from the worker; Forms B and C repeat the summary after assessment and treatment.