When the WSIB approves additional community treatment after the eight-week mild traumatic brain injury program of care, the treating provider reports on that supplementary block with this four-page form. It records whether the person completed the block or self-discharged, sessions provided, employment status, return to pre-injury function, Rivermead and Patient-Specific Functional Scale scores, and accommodations for return to work.
The registered regulated health professional delivering the program, such as a chiropractor, occupational therapist or physiotherapist, completes and signs the report.
Download the current version from the source each time; forms change without notice.
Mild traumatic brain injury program of care: Supplementary report
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Within two business days of the last treatment in the supplementary block. The mTBI fee schedule says that if the WSIB has not received the supplementary report within 14 days, the supplementary block is not paid. The report fee is built into the block code, MTBRST or MTBRSTV.
No. The mTBI fee schedule says not to bill the supplementary block electronically; treatment for blocks one and two is billed through TELUS Health at the end of each block, while reports generate an automatic invoice when submitted. Supplementary block payment is made once the supplementary report is received.
The WSIB's mTBI program page says a supplementary treatment block is available for injured people who are approved for additional treatment in the community. On this report you then record whether the person completed the block or self-discharged, how many sessions were provided and their employment status at discharge.