Assessment of Attendant Care Needs (Form 1) – SABS

Assessment of Attendant Care Needs (Form 1), effective as of October 1, 2016, is issued by the Financial Services Commission of Ontario (FSCO) for assessing the attendant care needs of individuals who have been in automobile accidents occurring on or after March 31, 2008. It must be completed by a qualified occupational therapist or registered nurse and is designed to outline the future care requirements of the applicant.

The form details various care activities, time estimates for these activities, and calculations for the total number of care minutes per week. It emphasizes the importance of reviewing other accident benefits available under the Statutory Accident Benefits Schedule (SABS) for potential reimbursements.

This form is essential for documenting and determining the extent of care needed for individuals affected by automobile accidents, ensuring they receive appropriate and adequate support.

Follow the steps below to ensure the form is accurately completed.

Step-by-Step Instructions

General Information

1. • Claim Number: Enter the claim number provided by the insurance company.
   • Policy Number: Enter the policy number from the applicant’s insurance policy.
   • Date of Accident: Provide the date of the accident in the format YYYYMMDD.

Applicant Information

1. • Fill in the applicant’s date of birth, gender, telephone number, and full name (last name, first name, middle name if applicable).
   • Provide the applicant’s complete address, including city, province, and postal code.

Insurance Company Information

1. • Enter the insurance company’s name and the city or town of the branch office if applicable.
   • Provide the telephone number of the insurance company.
   • Enter the policyholder’s name if different from the applicant’s.

Attendant Care Assessment Information

1. • Date of Assessment: Enter the date the assessment is being conducted.
   • First Assessment: Indicate if this is the first assessment of the applicant by checking ‘Yes’ or ‘No’.
   • Date of Last Assessment: If applicable, provide the date of the last assessment.
   • Current Monthly Allowance: Enter the current monthly allowance if applicable.

Assessor Information

1. • Provide the name, email address, profession, and college registration number of the assessor.
   • Include the name, HCAI Facility Registry Number, FSCO Licence Number (if applicable), service address, city, province, postal code, telephone number, and email address of the facility.

Part 1: Level 1 Attendant Care (Routine Personal Care)

1. • For each activity listed (e.g., dressing, undressing, grooming), estimate the time it takes to perform each activity and the number of times per week it should be performed.
   • Multiply the number of minutes by the number of times per week to get the total number of minutes per week for each activity.
   • Add all the subtotals to get the Part 1 total and enter it in Part 4.

Part 2: Level 2 Attendant Care (Basic Supervisory Functions)

1. • Similar to Part 1, estimate the time for each activity (e.g., hygiene, basic supervisory care) and calculate the total number of minutes per week.
   • Sum all the subtotals to get the Part 2 total and enter it in Part 4.

Part 3: Level 3 Attendant Care (Complex Health/Care and Hygiene Functions)

1. • Estimate the time for each complex care activity (e.g., bowel care, tracheostomy care) and calculate the total number of minutes per week.
   • Sum all the subtotals to get the Part 3 total and enter it in Part 4.

Part 4: Calculation of Attendant Care Costs

1. • Enter the total minutes per week for Parts 1, 2, and 3, then divide by 60 to get the total weekly hours.
   • Multiply the total weekly hours by 4.3 to get the total monthly hours.
   • Use the appropriate hourly rate (refer to the chart provided) to calculate the monthly care benefit for each part.
   • Sum the monthly care benefits to get the Total Assessed Monthly Attendant Care Benefit and enter it.

Part 5: Signature of Assessor(s)

1. • The assessor must sign and date the form, confirming the accuracy of the information and the consent from the applicant for the collection, use, and disclosure of the information submitted.

Attachments

1. • If there are any attachments, indicate ‘Yes’ and specify how many. Send any attachments directly to the insurer.

Final Steps

• Ensure all relevant parts of the form are completed.
• Make copies of the completed form and provide them to the applicant, the applicant’s health practitioner, and any other relevant parties.

This guide should help you accurately fill out the Assessment of Attendant Care Needs (Form 1). If you have any questions, consult the guidelines provided by the FSCO or contact the appropriate insurance representative.