Physiotherapist's extension request(s) and discharge report, including return-to-work barriers and recommendations.
- Completed by
- Physiotherapist
- Issued by
- Yukon Workers' Safety and Compensation Board
- Format
- Fillable PDF
- Language
- English
Yukon WSCB Physiotherapy Initial Assessment (F-0199)
Yukon physiotherapists complete this five-page fillable report after first assessing a worker with a work-related injury. It covers subjective and objective findings, special tests, a clinical impression, the worker's five most critical job demands matched against current ability, and a treatment plan with visits per week and expected duration. WSCB's case manager completes the last page to authorize treatment and set the next reporting date.
Who completes it
The treating physiotherapist completes and signs pages 1 to 4, including the clinic details and the therapist's email. WSCB's case manager completes page 5 and returns it to the provider.
Submitting and payment
- How to submit it
- Fax or mail it to WSCB using the contact details on the form; Yukon's Act requires health care providers to report within two days after first attending an injured worker.
- Who pays
- WSCB authorizes payment for the initial physiotherapy assessment, which may include the first treatment, before the claim is adjudicated, with later treatment and billing governed by the Physiotherapy Services Agreement.
Good to know
- On page 5, WSCB can approve the initial assessment and 2 treatment sessions, approve the plan as recommended or with modifications, decline it, deny the claim or ask you to call.
- List the worker's five most critical job demands with their current ability and whether it matches, and say whether a job demands analysis is needed.
- Recommend 1 to 4 visits per week, or other, for 4, 5 or 6 weeks, or other, plus any equipment or supplies the worker needs.
- In rural Yukon areas without physiotherapists, policy 3.10 favours an independent exercise program and tele-health consultations, where available, so the worker can recover at home.
Get the official form
Download the current version from the source each time; forms change without notice.
Physiotherapy initial assessment report
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
Does a Yukon worker need a referral for physiotherapy?
No. Policy 3.10 recognizes physiotherapists as primary care providers, so workers may self-refer. WSCB will authorize payment for the initial assessment, which may or may not include the first treatment, before the claim is adjudicated, provided the physiotherapist has signed the Physiotherapy Services Agreement or works for a signatory.
What follows the physiotherapy initial assessment?
Requests for further treatment and the discharge report go on the Physiotherapy Extension and Discharge Report (F-0203). Policy 3.10 requires a written request with rationale for treatment beyond the initial treatments, and WSCB may consult the worker's physician, a specialist or its medical consultant before approving a new treatment plan.
Do I have to give the worker a functional abilities form?
The return-to-work section asks whether a Functional Abilities Form (FAF) has been provided to the worker and, if not, why. It also asks whether the worker can perform regular duties based on current functional abilities and, if not, for a list of everything they can do.