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WSIB Cannabis Initial Assessment Form (0210A)

The WSIB sends this form to a worker's physician or nurse practitioner when it needs clinical information about an initial request for medical cannabis coverage for a work-related condition. It is not posted publicly, so clinicians see it only when the WSIB asks. The answers feed the WSIB's decision under its Cannabis for Medical Purposes policy, which limits coverage to designated conditions linked to the work injury or its treatment.

Who completes it

A physician or nurse practitioner completes the whole form. WSIB policy says the authorizing professional should be the one managing the worker's ongoing care, and if someone else authorizes cannabis, the primary treating professional must support its use.

Submitting and payment

How to submit it
Complete the copy the WSIB sends you and return it to the WSIB; if you fax a report, the WSIB fee schedule says not to send the original as well.
Who pays
The WSIB pays for completing it under fee code M630, listed on both the physician and the nurse practitioner fee schedules.

Good to know

  • Designated conditions under policy 17-01-10 include neuropathic pain, spasticity from spinal cord injury, chemotherapy-related nausea and vomiting, HIV/AIDS appetite loss, and palliative symptoms.
  • The policy requires an appropriate clinical assessment with measurable findings before initial entitlement, and conventional treatments must be exhausted first, except in palliative care.
  • For neuropathic pain, the policy expects trials of at least three first-line or second-line treatments and a pharmaceutical cannabinoid, with an adequate trial usually lasting three months.
  • The medical document must state milligrams of THC per day and the route of administration; the route must not involve smoking, and the policy sets daily limits.

Get the official form

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

Cannabis initial assessment form

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Where can I download WSIB Form 0210A?

You cannot. The cannabis initial assessment form is not posted on the WSIB website; the WSIB sends it when it needs clinical information about a worker's initial request for medical cannabis coverage. Complete the copy you receive, return it to the WSIB, and bill fee code M630.

What happens after the initial cannabis assessment?

If coverage is approved, policy 17-01-10 says the WSIB reviews it no more than three months after initial entitlement, then at intervals of no more than six months. When it needs clinical information for continued coverage, the WSIB sends the follow-up cannabis assessment form (0211A), billed under fee code M631.

Can a nurse practitioner complete the WSIB cannabis initial assessment?

Yes. The WSIB's cannabis policy defines the health professional who may authorize medical cannabis as a physician or a nurse practitioner, and the nurse practitioner fee schedule lists the cannabis initial assessment form under the same fee code, M630, as the physician fee schedule.