FSRA | SABS Forms – Application for Determination of Catastrophic Impairment (OCF-19)

Application for Determination of Catastrophic Impairment (OCF-19) – SABS

Application for Determination of Catastrophic Impairment (OCF-19), effective June 1, 2016, is used to determine if an individual has suffered a catastrophic impairment due to a motor vehicle accident. Individuals designated as catastrophically impaired are eligible for extended medical, rehabilitation, attendant care benefits, and other related expenses.

The form emphasizes the need for consent and proper disclosure of medical information and outlines the responsibilities of both the applicant and the physician in the determination process. It serves as a critical document in securing appropriate support and benefits for those severely impacted by automobile accidents.

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

Part 1: Applicant Information

Completed by the Applicant or Substitute Decision Maker

• Claim Number: Enter your claim number provided by your auto insurer.
• Policy Number: Enter your auto insurance policy number.
• Date of Accident: Write the date of the accident in YYYYMMDD format.
• Last Name: Enter your last name.
• First Name and Initial: Enter your first name and initial.
• Address: Provide your full address, including street, city, province, and postal code.
• Date of Accident: Re-enter the date of the accident in YYYYMMDD format.
• City: Enter the city where you reside.
• Province: Enter the province where you reside.
• Postal Code: Enter your postal code.
• Home Telephone: Provide your home telephone number.
• Work Telephone: Provide your work telephone number and extension, if applicable.
• Email (Optional): You may provide your email address.

Applicant Status

• Check the applicable box to indicate if you are under 18, currently in a hospital if this is your first application, or if this is a reapplication.

Authorization and Certification:

• Read the authorization statement carefully.
• Sign and date the form, certifying that the information provided is true and correct.

Part 2: Physician Information

Completed by the Treating Physician

• Name of Physician: Enter the full name of the physician.
• College Registration Number: Enter the physician’s college registration number.
• Facility Name: Enter the name of the facility where the physician practices, if applicable.
• AISI Facility Number: Enter the facility number, if applicable.
• Address: Provide the full address of the physician’s office or facility.
• City: Enter the city where the physician’s office or facility is located.
• Province: Enter the province where the physician’s office or facility is located.
• Postal Code: Enter the postal code of the physician’s office or facility.
• Telephone Number: Provide the telephone number of the physician’s office.
• Extension: Provide the extension number, if applicable.
• Fax Number: Provide the fax number of the physician’s office.
• Email (Optional): The physician may provide an email address.

Part 3: Physician’s Report of Catastrophic Impairment

Completed by the Treating Physician

• Knowledge of Applicant:
  • Indicate whether the applicant is currently under your care.
  • Provide the date the applicant was last seen for this application or for regular care.
  • If the applicant is no longer actively followed, provide the date last seen.
  • If the applicant was seen for the purpose of this application, provide the relevant dates.

Part 4: Criteria for Catastrophic Impairment

Completed by the Treating Physician

• Automatic Designation (Section A)
  • If the applicant is under 18 at the time of the accident and meets specific criteria (e.g., traumatic brain injury with positive findings on a scan), check the appropriate box.
• Criteria for All Applicants Not Subject to Section A (Section B)
  • Provide a description of the impairment(s) sustained in the automobile accident.
  • Check all applicable criteria that apply to the applicant, such as paraplegia, severe impairment of mobility, loss of vision, traumatic brain injury, physical impairment, or mental/behavioral impairment.

Additional Criteria

• Indicate if additional criteria apply, such as the impairment persisting for two years or being unlikely to improve.

Part 5: Signature of Physician

Completed by the Treating Physician

• Certification
  • Read the certification statement carefully.
  • Print the name of the physician.
  • Sign and date the form, certifying that the information provided is true and correct.

Appendix 1: Criteria for Part 4

• Refer to the summary of the catastrophic impairment criteria provided in this appendix when completing Part 4.

Submission

• Return the completed form to your auto insurer.

Notes

• Ensure that all sections are completed fully and accurately.
• Attach any necessary additional documentation, such as reasons for reapplication.
• Be aware of the legal implications of providing false or misleading information.