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WSIB Form 0389A: Home Oxygen Therapy Report

When home oxygen therapy is prescribed for a patient with a work-related injury or illness, the WSIB sends out this physician's report. The WSIB says it needs the form to decide both initial and ongoing entitlement to home oxygen, so the physician completes it and returns it to the WSIB. It is not among the downloadable provider forms; work from the copy the WSIB supplies.

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 M659, the code for the physician's report on home oxygen therapy.

Good to know

  • The WSIB physician fee schedule says the form is required to determine both the initial and the ongoing entitlement to home oxygen therapy.
  • Work-related chest illnesses have their own physician report, Form 8S (0407A), which the WSIB sends when a patient reports an occupational chest illness.
  • Accounts the WSIB receives more than six months after the date of service may be reduced, although late billing penalties may be waived when a good reason is given.
  • Section 37(1) of the Workplace Safety and Insurance Act requires health care practitioners to give the WSIB the information it needs, and PHIPA permits this disclosure without consent.

Get the official form

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

Physician's report - home oxygen therapy

Official page

Fill it with Vero

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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

Why does the WSIB need Form 0389A?

The WSIB physician fee schedule states that the form is required to determine the initial and ongoing entitlement to home oxygen therapy. The WSIB sends it when home oxygen therapy is prescribed for a work-related injury or illness, and the physician completes it and returns it to the WSIB for a set fee under code M659.

Can I download WSIB Form 0389A?

No. The home oxygen therapy report is not posted with the WSIB's downloadable health care provider forms; the WSIB supplies it when home oxygen therapy is prescribed. Complete that copy and return it to the WSIB, and if you fax it, do not also send the original.

Do I need my patient's consent to return the home oxygen 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.