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WSIB Form 0043A: Physician's Special Report

The WSIB sends out this physician's report when a patient is to be rated for a permanent disability and their accident happened before January 1, 1990. Those older claims fall under the WSIB's pre-1990 permanent disability policies, which rate the degree of disability using the Ontario Rating Schedule. The physician completes the WSIB-supplied form and returns it for a set fee under code M653.

Who completes it

The physician completes the whole form and returns it to the WSIB.

Submitting and payment

How to submit it
Complete the copy the WSIB supplies and return it to the WSIB; if you fax it, the physician fee schedule says not to also send the original.
Who pays
Bill the WSIB directly under physician fee code M653, listed in the physician fee schedule as the physician's special report.

Good to know

  • WSIB policy 18-07-01 says the degree of permanent disability is determined once treatment has concluded, the condition is stable and maximum medical recovery has been reached.
  • The WSIB reviews the available health care information to estimate clinical impairment, and may arrange an independent medical assessment if that information is insufficient or complicated by other conditions.
  • Ratings use the Ontario Rating Schedule, adapted from the Association of Workers' Compensation Boards of Canada schedule, with awards from 0.4 per cent to 100 per cent.
  • If a permanent disability worsens, the WSIB may reassess it based on the health care information on file.

Get the official form

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

Physician's special report

Official page

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.

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Frequently asked questions

When does the WSIB send the physician's special report?

The WSIB physician fee schedule says the WSIB sends this form when a person is to be rated for a permanent disability and their accident precedes January 1, 1990. The form is not posted for download, so complete the copy the WSIB supplies and return it to the WSIB for payment under code M653.

How does the WSIB rate permanent disability for pre-1990 accidents?

Under policy 18-07-01, the WSIB rates the degree of permanent disability when treatment has concluded, the condition is stable and maximum medical recovery is reached. It reviews the health care information on file, may arrange an independent medical assessment, and applies the Ontario Rating Schedule, with awards from 0.4 per cent to 100 per cent.

Do I need my patient's consent to return the special report?

The WSIB's reporting requirements page cites section 37(1) of the Workplace Safety and Insurance Act, which requires health care practitioners to share the information the WSIB needs, and section 43(1)(h) of the Personal Health Information Protection Act, which allows a health information custodian to disclose health information to the WSIB without consent.