Ontario chiropractors use this one-page request when a worker needs chiropractic treatment beyond the initial allowed period. The form warns that the WSIB will not pay for treatment past 12 weeks unless it pre-authorizes an extension. It covers the working diagnosis and any change, treatment results to date, work status, current findings and limitations, expected improvement, and the duration and frequency of further treatment.
The treating chiropractor completes the entire form, including the patient's details and claim number, and signs it, or ticks the electronic-signature box after entering their name and date. The worker and employer do not complete any part.
Download the current version from the source each time; forms change without notice.
Chiropractor's treatment extension request
Demande de prolongation des traitements (chiropraticien)
Upload the fillable PDF 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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At least four weeks before the 12-week treatment period ends. The form states that chiropractic treatment will not be paid beyond 12 weeks unless the WSIB pre-authorizes an extension, and that the request must be completed in full and submitted early to keep treatment continuous.
No. The WSIB chiropractic fee schedule states that no fee is paid for completing the Chiropractor's Treatment Extension Request form. The Health Professional's Report (Form 8) is billable for chiropractors, under code 8M1 for paper submission or 8M1E for electronic submission, but only one Form 8 is submitted per person.
No. The WSIB's health care provider forms page says not to submit treatment extension requests for anyone being treated in a program of care, such as the musculoskeletal program of care. For case-specific clinical concerns, the WSIB directs providers to its Clinical Expert Line.