A. Patient and employer information (patient to complete section A)
The patient enters their name, address, telephone, date of birth, sex and language, the employer's name and address, a supervisor or contact name with telephone, and their job title or occupation. Add the claim number at the top if one exists. Review the section for completeness before submitting; the WSIB collects this information to administer the Workplace Safety and Insurance Act.
B. General section
Record whether the patient says their psychological condition is due to work, the date they first sought medical care for it and the date symptoms began. Indicate whether the condition continues, or give the date of last symptoms or resolution. Question 3 asks, in your own words, for your understanding of the work-related situation or situations that led to the reported condition.
C. Clinical information section
Document the diagnosis and, if met, the criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM); the form asks for a DSM diagnosis where possible. WSIB's chronic mental stress policy requires a DSM diagnosis before a claim can be adjudicated. Then answer whether you know of pre-existing or co-existing psychological conditions or other contributing factors (yes, no or unknown), briefly describing the diagnosis, onset date and previous treatment if known.
D. Treatment plan
Describe the treatment plan, including the type of treatment, its duration, prescribed medications and any recommended referrals. Sections B to E sit on page 2, which goes to the WSIB along with page 3. Only page 3 is given to the patient, who can pass it to their employer if needed, so the clinical details on page 2 do not go to the employer.
E. Billing section
Tick physician or nurse practitioner, then enter your WSIB provider ID, invoice number, service date, name, address, telephone and fax. The service code is pre-printed as 8CMS; the physician and nurse practitioner fee schedules list the report under CMS8 as a paper-submission fee. Fill in the HST registration number and amount, under code ONHST, only if HST applies.
F. Return-to-work information: must be completed by a health professional
Page 3 is the only page the patient gives their employer. Say whether the patient lost time from work; if they are off, tick regular or modified duties with a start date and any graduated hours, or that they cannot work, with an explanation and what would need to be in place for a return in any capacity. Describe functional abilities (full, impaired with accommodations required, or other limitations), add the follow-up plan, then sign.
G. Patient's signature
The patient signs to authorize you to give their employer a copy of page 3 outlining their functional abilities, and acknowledges that a copy goes to the WSIB. When the form is completed and submitted electronically, you and the patient can each tick the box that stands in for a signature, but the name and date fields must still be filled in.