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WorkplaceNL Devices and Supplies Prescription Form

WorkplaceNL uses this one-page prescription to review coverage of a health care device or supply for an injured worker, from a back brace or cane to a raised toilet seat. You name each item with its model or catalogue number and sizing, explain the rationale in relation to the compensable injury, and note the best alternative if it cannot be obtained. WorkplaceNL then decides coverage under its medical effectiveness test.

Who completes it

The prescribing health care provider completes the whole form, from the worker's name and claim number to their own name, professional designation, organization, phone number and signature. WorkplaceNL lists it among the forms for physicians, physiotherapists and occupational rehabilitation providers.

Submitting and payment

How to submit it
Send it to WorkplaceNL by mail, fax or email, as printed on the form; occupational rehabilitation providers can also upload it through MyWorkplaceNL's document submission service.
Who pays
WorkplaceNL covers the cost of approved items, and its Procedure 58.00 encourages pre-authorization to ensure reimbursement; the form itself lists no completion fee.

Good to know

  • WorkplaceNL cannot buy items sold online, so check its list of tendered items, linked from the form, which sets out products by body part with brand, sizes and warranty.
  • Every item needs a rationale from the health care provider, and Procedure 58.00 allows coverage to be refused where a reasonable non-prescription alternative exists.
  • The prescribing health care provider cannot also be the supplier of the prescribed device, and workers are directed to suppliers with WorkplaceNL agreements wherever possible.
  • Physiotherapists who recommend an assistive device on Form PR may also need to complete this prescription, according to WorkplaceNL's Form PR completion instructions.

Get the official form

Download the current version from the source each time; forms change without notice.

Health Care Devices and Supplies Prescription

Official pagePDF

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.

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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

What does WorkplaceNL need on a health care devices and supplies prescription?

Each item prescribed, with its model or catalogue number and sizing if applicable, whether it is a replacement, the rationale in relation to the compensable injury and whether the worker has trialed it. You also note the best alternative if the item cannot be obtained, then add your name, professional designation, organization, phone number, signature and date.

Can WorkplaceNL pay for a device bought online?

No. The form states that online items cannot be purchased by WorkplaceNL. It links to the list of tendered items, a standing offer that lists products by body part with brand, sizes and warranty, and Procedure 58.00 says workers are directed to suppliers with WorkplaceNL agreements wherever possible.

Does the device need approval before the worker buys it?

Procedure 58.00 encourages pre-authorization to ensure reimbursement. If the worker buys an item first and then claims reimbursement, the decision maker determines entitlement at that point. Requests for non-standard or experimental items need a written submission from the treating provider and go to a WorkplaceNL Health Care Consultant for a medical opinion first.