For contact and submission details, see the last page of this form. Physiotherapy report type




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Physiotherapy Report

For contact and submission details, see the last page of this form.

Physiotherapy report type (please check one)

Stream 1 • Standard Treatment (PS)  Stream 2 • Exceptions to Standard Treatment (PE)  Hydrotherapy (HY) 

Stream 3 • Home Visits (PH)  Stream 4 • CNS Disorder Treatments (PC)  Requested (PR) 



Date of service (= date of this report) (yyyy-mm-dd)

     


Worker information

Worker last name

     


First name

     


Middle initial

     


Personal health number

     


Date of birth (yyyy-mm-dd)

     


Worker’s occupation

     


WorkSafeBC claim number

     


Clinical status

Date of injury (yyyy-mm-dd)

     


Injury accepted on claim

     


Is worker currently working?

Yes  No 



Date of initial visit (yyyy-mm-dd)

     


Reassessment date (yyyy-mm-dd)

     


Number of visits to date

     


Initial objective findings (include specific measurements)

     


Current objective findings if applicable
(include specific measurements)

     


Critical job demands as reported by the worker
(include specific measurements)

     


Current functional abilities related to critical job demands listed (include specific measurements)

     


Factors delaying recovery

     


Treatment goals

Expected improvements (measurable objective findings and functional abilities related to critical job demands)

     


Can modified or regular duties be performed concurrently with physiotherapy treatment?

Yes  No  Please explain

Expected start date (yyyy-mm-dd)            


Recommendations (Streams 2, 3, or 4 only)

Physiotherapy treatment 
Start date (yyyy-mm-dd)

     


Number of weeks

     


Expected number of visits

     


Expected outcome at end of treatment

Return to pre-injury work  Occupational Rehab 1 (OR1) 

Return to modified or alternate work  Further medical investigation 

RTW support services (RTWSS)  Other (please specify) 
     


Provider information

Physiotherapist’s name

     


Practitioner number

     


Clinic payee number

     


Clinic name

     


Clinic phone number

(     )      



Clinic fax number

(     )      



Date (yyyy-mm-dd)

     


Physiotherapist’s mailing address/stamp

     


Signature


Message to physical therapist

  • Physiotherapy treatment will only be paid within the period pre-authorized by WorkSafeBC.

  • For Stream 1, the physical therapist must submit a Physiotherapy Report (form 268):

    • at least five (5) business days prior to the treatment end date if the worker is not expected to return to pre-injury hours and duties or

    • within five (5) business days from recommending transfer to Stream 2 as a result of a significant change in worker’s condition.

  • For Stream 2, the physical therapist must contact the WorkSafeBC officer at least ten (10) business days prior to the end date if the expected outcome will not be achieved at the end of the treatment plan.

  • For Streams 3 and 4, the physical therapist must contact the WorkSafeBC officer at least five (5) business days prior to the end date if the expected outcome will not be achieved at the end of the treatment plan.

  • For Hydrotherapy, the physiotherapist must submit Physiotherapy Report form 268 for hydrotherapy extensions for treatments beyond the first five sessions.

  • If notice of approval or rejection of the treatment plan is not received within five (5) business days of submission of the Physiotherapy Report, the physical therapist may initiate Stream 2, 3, and 4 treatment plans and will be compensated by WorkSafeBC for the services until communication is received from the WorkSafeBC officer. Treatment shall not continue beyond the parameters outlined in the initial treatment plan. Not applicable for transfers from Stream 1 to Stream 2.

  • For more information, refer to the Physiotherapy Services Reference Manual on WorkSafeBC.com.

  • Billing report codes: Stream 1 (19185), Transfer from Stream 1 to Stream 2 (19185), Stream 2 (19203), Stream 3 (19173), Stream 4 (19175), Hydrotherapy (19199).

  • Billing late report codes: Stream 1 (19186), Transfer from Stream 1 to Stream 2 (19186), Stream 2 (19187), Stream 3 (19189), Stream 4 (19197).

  • Reports are to be sent to WorkSafeBC by FAX at 604 233-9777 or toll-free 1 888 922-8807.

  • If you have any questions about this form, contact Health Care Services at 604 232-7787 or toll free
    1 866 244-6404.

Personal information on this form is collected for the purposes of administering a worker’s compensation claim by WorkSafeBC in accordance with the Workers Compensation Act and the Freedom of Information and Protection of Privacy Act. For further information about the collection of personal information, please contact WorkSafeBC’s Freedom of Information Coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or telephone 604 279-8171.

(R08/12) Page of

Workers’ Compensation Board of B.C.

268





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