WCB Nova Scotia uses this form when a physician recommends an assistive device for a worker's compensable injury. The case worker fills in the request and worker details, and the physician describes the device, whether it is new or a replacement, any leg length discrepancy if orthotics or footwear are prescribed, and the rationale and benefit in relation to the injury, with supporting evidence where needed.
The WCB case worker completes Sections A and B; the physician completes Section C on the device and Section D with their name, professional designation, WCB ID number, signature, phone and fax.
Download the current version from the source each time; forms change without notice.
Physician – Assistive Devices Request Form
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.
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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Two people. A WCB case worker completes Section A, the request information, and Section B, the worker's details including compensable injury and body part. The physician completes Section C, describing the device and its rationale, and Section D with their name, professional designation, WCB ID number, signature, phone and fax.
The form asks for the rationale and benefit of the device in relation to the compensable injury and, where necessary, medical or scientific evidence supporting the request. You also state the type of device, whether it is new or a replacement, and for orthotics or footwear whether there is a leg length discrepancy.