FSRA | SABS Forms – Auto Insurance Standard Invoice (OCF-21)

Auto Insurance Standard Invoice (OCF-21) – SABS

The Auto Insurance Standard Invoice (OCF-21) is a comprehensive form used in Ontario, Canada, for invoicing medical and rehabilitation goods and services payable by an automobile insurer. This form applies to accidents that occurred on or after November 1, 1996. It includes multiple sections designed to capture detailed information about the applicant, insurance company, invoice specifics, and payee information.

The form is utilized to bill for medical and rehabilitation services provided to automobile accident victims. It ensures that all necessary information is collected for processing claims and payments. Specific versions of the form (Version A, B, or C) are attached depending on the type of service or injury guideline being billed.

This document adheres to privacy legislation, ensuring that the collection, use, and disclosure of personal information comply with applicable laws. It requires the applicant or their representative to consent to the collection and use of information for processing claims and preventing fraud.

Attachments such as treatment plans or assessments may be required, depending on the nature of the injury and services provided. The form includes declarations about the accuracy of the provided information and acknowledgments regarding the legal implications of submitting false or misleading information.

The OCF-21 form is a critical document for ensuring the accurate and lawful processing of insurance claims for medical and rehabilitation services in Ontario. Follow these steps to complete the form accurately:

Part 1: Applicant Information

• Date of Birth: Enter the applicant’s date of birth in the format YYYYMMDD.
• Gender: Check the appropriate box for male or female.
• Telephone Number and Extension: Provide the applicant’s telephone number and extension, if applicable.
• Last Name, First Name, and Middle Name: Enter the applicant’s full name.
• Address, City, Province, Postal Code: Fill in the applicant’s complete address.

Part 2: Insurance Company Information

• Company Name: Enter the name of the insurance company.
• City or Town of Branch Office: If applicable, provide the location of the branch office.
• Adjuster Last Name and First Name: Provide the name of the adjuster handling the claim.
• Adjuster Telephone and Extension: Enter the adjuster’s contact number and extension, if applicable.
• Adjuster Fax: Provide the adjuster’s fax number.
• Name of Policyholder: If the policy holder is the same as the applicant, check the appropriate box. Otherwise, enter the policyholder’s last name and first name.

Part 3: Invoice Information

• Invoice Number: Assign a unique invoice number.
• First Invoice and Last Invoice: Check ‘Yes’ or ‘No’ as applicable.
• Type of Plan or Minor Injury Guideline: Specify the type of plan or guideline.
• Plan Date and Plan Number: Enter the date and number of the approved plan.
• Approved Amount and Previously Billed: Fill in the amounts as applicable.
• Attachment: Indicate the version of the form attached (Version A, B, or C).

Part 4: Payee Information

1. Service Address: If the service address is the same as the billing address, check the box. Otherwise, complete the service address section.
2. Facility Name: Enter the name of the facility, if applicable.
3. HCAI Facility Registry Number and FSCO Licence Number: Provide these numbers if applicable.
4. Payee Last Name, First Name, and Number: Enter the payee’s details.
5. Billing Address and Service Address: Fill in the complete billing and service addresses.
6. City, Province, and Postal Code: Provide the corresponding information.
7. Telephone Number, Fax Number, and Email Address: Enter the contact details for the payee.

Declaration and Certification

• Name of Provider or Authorized Signatory: Print the name of the person completing the form.
• Signature and Date: Sign and date the form to certify the information is true and correct.

Additional Notes

• Confidentiality: Ensure that the information collected, used, and disclosed complies with all applicable privacy legislation.
• Attachments: Send all necessary attachments directly to the insurer.
• Instructions for Different Versions:

• Version A: Use for previously approved treatment or assessment plans.
• Version B: Use for all other goods and services and may be used for previously approved plans at the provider’s discretion.
• Version C: Attach for billing goods and services within the Minor Injury Guideline.

Tips

• Double-check all fields for accuracy before submitting.
• Contact the insurance company representative or a legal advisor if you have questions about the form or consent.

By following these steps, you can ensure that the Auto Insurance Standard Invoice (OCF-21) is filled out correctly, facilitating efficient processing of claims and payments.