Rapport d'évaluation de physiothérapie
Physiotherapist's assessment report to the WSIB (patient, employer, findings and plan) for a work-related injury.
- Completed by
- Physiotherapist
- Issued by
- WSIB
- Format
- Fillable PDF
- Language
- English and French
WSIB Form 0153A: Physiotherapy Treatment Extension
Physiotherapists use this one-page WSIB form, printed as the Physiotherapist's treatment extension report, to ask for treatment beyond the initial 12-week period. The form states that physiotherapy is not paid past 12 weeks unless the WSIB pre-authorizes an extension. It summarizes treatment and results to date, current findings and limitations, work status, expected outcomes and the further treatment proposed.
Who completes it
The treating physiotherapist completes and signs the whole form, by hand or by ticking the electronic-signature box and entering their name and the date.
Submitting and payment
- How to submit it
- Upload it at wsib.ca/submit (online services login required) or fax it, completed in full, at least four weeks before the 12-week treatment period ends.
- Who pays
- No fee is paid for completing this form; the WSIB physiotherapy fee schedule lists it without a service code.
Good to know
- Do not submit a treatment extension request for anyone being treated in a program of care, such as the musculoskeletal program of care.
- The form asks whether the working diagnosis has changed since the initial diagnosis and, if so, for the new working diagnosis.
- Record whether the worker lost time or returned to regular or modified work, and whether they would benefit from a multi-disciplinary health care assessment.
- Give the expected improvements, whether complete recovery is expected and roughly when, plus start and end dates and the frequency of further treatment.
Get the official form
Download the current version from the source each time; forms change without notice.
Physiotherapist's treatment extension request
Demande de prolongation des traitements de physiothérapie
Fill it with Vero
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.
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 must the WSIB physiotherapy extension request be submitted?
At least four weeks before the 12-week treatment period ends. The form says physiotherapy is not paid beyond 12 weeks unless the WSIB pre-authorizes an extension, and that it must be completed in full to ensure continuity of treatment. The physiotherapy fee schedule repeats the four-week lead time.
Is the physiotherapist paid for Form 0153A?
No. The WSIB physiotherapy fee schedule lists the physiotherapist treatment extension request without a service code and states that no fee is paid for completing it. The physiotherapy assessment report (0856A), completed when treatment begins, is billed separately under P970.
Can I use Form 0153A for a patient in the MSK program of care?
No. The WSIB's health care forms page says not to submit treatment extension requests for anyone being treated in a program of care. Since May 1, 2023, community-based musculoskeletal treatment goes through the MSK program of care, where additional treatment is handled through an approved supplementary block instead.