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WorkSafeBC 83D600: Concussion Physio Extension Request

Contracted concussion and vestibular physiotherapists use this six-page form to ask WorkSafeBC to extend CVPT treatment. It sets out the duration, visits requested and end date, changes in symptoms and outcome measures since the assessment, repeat objective screens including VOMS and balance testing, whether function has measurably improved, the rationale, treatment goals and plan, and return-to-work recommendations.

Who completes it

The contracted CVPT physical therapist completes the whole request, listing all previous outcome scores with the dates they were obtained.

Submitting and payment

How to submit it
Upload it through WorkSafeBC's claims uploader if you bill in Teleplan, or through My Provider Services if you bill there; the form also lists fax and mail.
Who pays
WorkSafeBC pays under its CVPT fee schedule, and the invoice's date of service must match the date the report was submitted, as entered on the form.

Good to know

  • If function has not measurably improved, based on the subjective and objective information, explain why before giving the rationale for more treatment.
  • Give the initial assessment date, total visits to date, average visits per week and the duration of the requested extension in weeks.
  • Match each essential job duty against the worker's measured functional ability and say whether regular or modified duties can be done alongside treatment.
  • Treatment goals must be specific and measurable, achievable by the end of the proposed plan, with the exercise progressions planned to reach them.

Get the official form

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

Concussion and Vestibular Physiotherapy (CVPT) Extension Request

Official page

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Frequently asked questions

What does WorkSafeBC need to extend concussion physiotherapy?

A completed CVPT Extension Request showing changes in symptoms, outcome measures and objective screens since the assessment, whether function has measurably improved, and a rationale. It must also give specific, measurable goals, the proposed plan, visits requested and an end date, plus return-to-work recommendations.

Which date of service goes on the CVPT extension request?

The date the report is submitted. The form says the date of service on the invoice must match the date of service on the form for payment to be processed. The extension follows the CVPT Assessment Report (83D599), and treatment ends with the CVPT Discharge Report (83D601).