A dentist treating a work-related injury to a patient's teeth or mouth reports it to the WSIB on this two-page form. Page 1 charts the teeth as they were before the accident and the damage the accident caused; page 2 is a pre-determination table of proposed treatment by ODA procedure code and fee. The WSIB must authorize all treatment except x-rays and emergency services before it goes ahead.
The dentist completes the whole form, ticking the Specialist box if applicable, and signs it or, when submitting electronically, ticks the box that stands in for a signature and types their name and the date. The worker's own report of the injury (Form 6, now online only) and the employer's Form 7 are filed separately.
Download the current version from the source each time; forms change without notice.
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.
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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For most treatment, yes. The form's instructions require prior authorization from the WSIB for all treatment except x-rays and emergency services. List the proposed services in the pre-determination table on page 2 by date, ODA procedure code, tooth code, surface, dentist's fee and laboratory charge, and describe any emergency treatment you have already given.
No. Dental services are paid at fees approved by the WSIB, which follow the Ontario Dental Association fees for general dentistry, and the form states that the patient or any other insurer is not responsible for any balance above those fees. Copies of laboratory invoices should accompany all billings.
Yes. The WSIB publishes a French version, Rapport du dentiste (0278B), and the English form notes that it is available in French. Whichever version you use, complete it in detail, attach pre-treatment x-rays and upload it with any supporting documents through WSIB online services at wsib.ca/submit.