Form 4 Satutory Accident Benefit Schedule

Ontario Automobile Insurance Application Medical or Psychological Report













Date of Accident


Date of First Visit

Instructions


1- Identity of Claimant












Date of Birth


Area Code - Home Telephone Number


Area Code - Work Telephone Number



















2 - Treating Practitioner

Doctor
Last name






Area Code - Work Telephone Number



Area Code - Fax Number














3 - Examination/Objective Findings

Date you most recently examined this patient














4 - Investigations/Test Results



5 - Diagnosis or Classification





6 - Treatment Plan

Investigations



Medications




Physiotherapy






Plan of Return Visits

:


7 - Duration of Disability



8 - Signature of Physician or Psychologist




Date

The fee for completion of this form is not a health care benefit of the Ontario Ministry of Health. That fee, and the cost of any examinations not covered by the Health Insurance System, should be billed to the automobile insurer to whom this form is submitted.

Submission of a completed and signed form to the insurer constitutes a request for payment for its completion. No other invoice will be submitted.