Health care providers other than physicians use this form to ask WCB Nova Scotia to approve an assistive device for a worker's compensable injury. After the case worker adds the request and worker details, the provider describes the device, whether it is new or a replacement, its cost and warranty, and the rationale and benefit, with a separate section for orthotics and footwear. WCB records its decision at the end.
The WCB case worker completes Sections A, B and F; the provider completes Section C, Section D if prescribing orthotics or footwear, and Section E with their name, professional designation, WCB ID number and signature.
Download the current version from the source each time; forms change without notice.
Service Provider – 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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Section D asks whether orthotics can be worn in standard footwear, why off-the-shelf footwear is not suitable if you are providing custom footwear, and whether there is a leg length discrepancy. For replacements, you confirm the current orthotics or footwear no longer provide a mechanical or medical benefit.
The WCB case worker completes Section F, the WCB response, marking whether the device is approved and adding their name, phone number and the date. WCB states that only services it has pre-authorized are guaranteed for payment, so the approval matters before the device is supplied.