Physician's report to WCB PEI for a work-related injury: accident description, clinical findings, diagnosis, work capacity and fee codes.
- Completed by
- Physician
- Issued by
- WCB PEI
- Format
- Fillable PDF
- Language
- English
WCB PEI Physiotherapist Report Form
Physiotherapists treating a worker with a Workers Compensation Board of PEI claim use this one-page report at the initial assessment, for progress updates, at discharge and to amend billing. It records treatment dates, diagnosis, objective findings, goals and treatment plan, recommended work status and an expected return-to-work date, and includes a box to request work conditioning or work hardening.
Who completes it
The treating physiotherapist completes and signs the whole report. The worker and employer report the injury separately on the Worker's Report (Form 6) and the Employer's Report (Form 7).
Submitting and payment
- How to submit it
- Fax the completed report to WCB PEI, or submit it electronically through WCB PEI Online Services for health care providers after signing up through its self-registration page.
- Who pays
- Billing goes to WCB PEI through the form's Fee Code field, with a Report Only box and an Amended Billing option; the WCB's forms page does not post a fee schedule.
Good to know
- Tick one report type at the top: Initial Assessment, Progress Report, Discharge Report or Amended Billing; the injury history box is completed for the initial assessment only.
- A checkbox lets you request work conditioning or work hardening, next to the one confirming that education or a home program was provided.
- Recommended work status options are full duties, not able, ease back or modified duties, and the form ends with an expected return-to-work date.
- The current version is dated November 2015, and the PDF is a print form without fillable fields, so online submission is the electronic option.
Get the official form
Download the current version from the source each time; forms change without notice.
Physiotherapist Report
Fill it with Vero
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.
How this list is checked
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Frequently asked questions
How do physiotherapists submit reports to WCB PEI?
By fax, or electronically through WCB PEI Online Services for health care providers, which lets providers submit an electronic Physiotherapist or Chiropractor Report and a Physician Report (Form 8). Providers sign up through the WCB's online self-registration. The PDF version is a print form without fillable fields.
How do I request work hardening from WCB PEI?
The Physiotherapist Report has a checkbox labelled Request for work conditioning / work hardening, beside the education or home program box. The same page carries your current objective findings, goals, treatment plan and time frames, and the recommended work status, which give the WCB the context for the request.
What work status can a physiotherapist recommend on the form?
Four options: full duties, not able, ease back or modified duties. The form also asks for an expected return-to-work date and lets you flag conflicting circumstances, such as compliance, with an explanation. Record treatment dates, total treatments and missed appointments with the reason near the top.