FSRA | SABS Forms – Treatment and Assessment Plan (OCF-18)

Treatment and Assessment Plan (OCF-18) – SABS

The Treatment and Assessment Plan (OCF-18) is a comprehensive document used in the context of automobile insurance claims in Ontario. This form is designed for accidents occurring on or after November 1, 1996, and is required for certain claims related to accident benefits.

The OCF-18 form includes sections for both the applicant and regulated health professionals to fill out. The applicant must provide personal and insurance information, review the plan with their health professional, and give consent. The health professional must complete the plan based on their examination of the applicant and certify the necessity of the proposed treatment.

The OCF-18 form document addresses privacy and consent regulations, ensuring that the collection and use of personal information comply with applicable laws. It must be completed with accuracy to avoid penalties under the Insurance Act and the Federal Criminal Code. It is essential for all parties involved to understand their roles and responsibilities in the completion and submission of the form.

The OCF-18 is part of a regulatory framework aimed at managing and processing accident benefit claims, preventing fraud, and ensuring appropriate treatment and rehabilitation of accident victims. Follow this step-by-step guide to ensure that you complete the form accurately and thoroughly.

Part 1: Applicant Information

• Date of Birth: Enter your date of birth in YYYYMMDD format.
• Gender: Select either Male or Female.
• Telephone Number: Provide your primary contact number and extension if applicable.
• Last Name, First Name, Middle Name: Enter your full legal name.
• Address, City, Province, Postal Code: Fill in your complete residential address.

Part 2: Insurance Company Information

• Insurance Company Name: Write the name of your insurance company.
• City or Town of Branch Office: If applicable, enter the location of the branch office handling your claim.
• Adjuster Last Name, First Name: Provide the name of your insurance adjuster.
• Adjuster Telephone Number, Extension, Fax: Enter the adjuster’s contact details.
• Policyholder Name: If different from the applicant, provide the policyholder’s name.

Part 3: Other Insurance Information

• Other Insurance Coverage: Indicate if there is other insurance coverage for the goods and services listed in the plan. Select Yes or No.
• Ministry of Health (MOH) Coverage: Indicate if there is MOH coverage for any listed goods and services. Select Yes, No, or Not applicable.
• Other Insurer Details: If applicable, provide information about other insurance policies that might cover the goods and services.

Part 4: Signature of Health Practitioner

• Health Practitioner Information: Enter the health practitioner’s name, college registration number, and select their profession (e.g., Chiropractor, Physician).
• Facility Name and Registry Number: If applicable, provide the facility’s name and registry number.
• Service Address: Provide the address of the health practitioner’s office.
• Minor Injury Guideline: Indicate if the impairment falls under the Minor Injury Guideline and provide additional details if necessary.
• Signature and Date: The health practitioner must sign and date this section.

Part 5: Signature of Regulated Health Professional

• Regulated Health Professional Information: Provide the name, college registration number, and profession of the regulated health professional.
• Facility Information: Enter the facility’s name, registry number, and address.
• Signature and Date: The regulated health professional must sign and date this section.

Part 6: Injury and Sequelae Information

• Description and ICD-10-CA Code: List the most significant injuries or conditions resulting from the accident and their corresponding ICD-10-CA codes.

Part 7: Prior and Concurrent Conditions

• Pre-existing Conditions: Indicate if there were any pre-existing conditions that could affect the response to treatment. Select Yes, No, or Unknown, and provide details if applicable.
• Concurrent Conditions: Indicate if any conditions developed after the accident that could affect treatment. Select Yes, No, or Unknown and provide details if applicable.

Part 8: Activity Limitations

• Employment and Daily Activities: Indicate if the injuries affect employment tasks or daily activities. Select Yes, No, or Unknown and provide details if applicable.
• Modified Employment: If applicable, indicate if the employer can provide modified work.

Part 9: Plan Goals, Outcome Evaluation Methods, and Barriers to Recovery

• Goals: Identify goals regarding pain reduction, range of motion, strength, and functional goals like returning to normal activities or work.
• Evaluation Methods: Describe how progress towards these goals will be evaluated.
• Barriers to Recovery: Indicate any barriers to recovery and provide recommendations to overcome them.
• Concurrent Treatment: List any other concurrent treatments not included in this plan.

Part 10: Signature of Applicant

• Applicant Consent: The applicant must read the consent and privacy information carefully.
• Signature and Date: The applicant or their substitute decision-maker must sign and date this section.

Part 11: Health Care Providers

• Provider Information: List all healthcare providers involved, their registration numbers, and hourly rates if applicable.

Part 12: Proposed Goods or Services Requiring Insurer Approval

• Goods and Services: List all proposed goods and services, their descriptions, codes, quantities, measures, and costs.
• Initials for Consent: The applicant must initial to confirm consent to the proposed goods and services.
• Attachments: Indicate if there are any attachments and how many.

Part 13: Signature of Insurer

• Insurer’s Decision: The insurer reviews and either approves, partially approves, or does not approve the treatment plan.
• Signature and Date: The adjuster must sign and date this section and provide copies to the relevant parties.

Additional Tips

• Ensure all information is accurate and complete to avoid processing delays.
• Use clear and legible handwriting or type the information if possible.
• Attach any required supporting documents directly to the insurer.

For any questions or assistance, contact your health practitioner, insurance representative, or legal advisor.