Return this form to: Treatment and Assessment Plan

(OCF-18)
Use this form for accidents that occur on or after November 1, 1996.

**Claim Number:

**Policy Number:
Date of Accident:
(YYYYMMDD)

- ambulance or other goods or services provided on an emergency basis not

more than 5 business days after the accident
- drugs prescribed by a regulated health professional
NOTE: A Treatment and Assessment Plan (OCF- 18) is not required to make the - dental goods or services (submitted on the Standard Dental Claim Form)
following claims: - goods referenced in s.15(1)(d) to (f) and s.16(3)(h) to (j) with a cost of $250 or
less per item
- goods and services referenced in s.15(1)(h) or 16(3)(l) if the insurer agrees the
expense is essential for the treatment or rehabilitation of the insured person
with a cost of $250 or less per item or service
If this is an impairment that comes within the Minor Injury Guideline applicable to the accident (for accidents that occurred on or after September 1, 2010) an
OCF – 23 Treatment Confirmation Form is required instead of this form.

To the Applicant: To the Regulated Health Professional/Facility:

Please provide information for the completion of Parts 1 and 2 and 3. After your To the extent possible, this Treatment and Assessment Plan should include all goods
regulated health professional has reviewed your Treatment and Assessment Plan and services contemplated by the regulated health professional referred to in Part 5.
with you, sign Part 10 and initial Part 12.
A health practitioner (i.e., chiropractor, dentist, nurse practitioner, occupational
Your regulated health professional will complete all other parts of the form. therapist, optometrist, physician, physiotherapist, psychologist, speech language
pathologist) must sign Part 4.
Collection, use and disclosure of this information are subject to all applicable privacy
legislation. Additional disclosure and consent may be required depending on the Complete Part 6 based on your most recent examination of the applicant named and
manner in which the information is used and disclosed. return the form to the insurance company listed in Part 2. Please print clearly.
As indicated on the form, all attachments are sent directly to the insurer. Consent: It is the responsibility of regulated health professionals to ensure that their
collection, use and disclosure of information submitted are authorized by a consent
All fields must be completed subject to the following exceptions: form. Ontario Claims Form 5 (OCF – 5) Permission to Disclose Health Information
*required if known may be used as a consent form.
**at least one field in this section
***optional

Date Of Birth (YYYYMMDD) Gender: Male Female *Telephone Number Extension

Part 1
Applicant
Information Last Name

To be provided by
the applicant First Name ***Middle Name

Address

City Province Postal Code

Insurance Company Name City or Town of Branch Office (if applicable)

Part 2
Insurance
*Adjuster Last Name *Adjuster First Name
Company
Information
*Adjuster Telephone Extension *Adjuster Fax
To be provided by
the applicant
**Name of Policy Holder **Policy Holder Last Name *Policy Holder First Name
same as Applicant , OR:

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 TO THE INSURER TO WHOM THIS APPLICATION IS BEING SUBMITTED:
Part 10
Signature of I UNDERSTAND that you, and persons acting for you, will collect personal information and personal health information about me that is related to my
Applicant claims for accident benefits arising out of the accident referenced in this Treatment and Assessment Plan, and that all such information will be collected
directly from me or from any other person with my consent.
Must be
completed unless I ALSO UNDERSTAND that you and persons acting for you will collect information about this Treatment and Assessment Plan prepared by my health
waived by insurer care provider(s).

I ALSO UNDERSTAND that if I am the holder of an automobile insurance policy, you, and persons acting for you, will collect the information related to
this claim that is provided by me on this or any other auto insurance claim form.

I ALSO UNDERSTAND that the information described above will be collected and used only as reasonably necessary for the purposes of:
• Investigating my claims and processing my claims as required by law, including the Ontario Automobile Policy;
• Obtaining or verifying information relating to my claims in order to determine entitlement and the proper amount of payment;
• Recovering payment from insurers and others liable in law for amounts that you pay in connection with my claims;
• Identifying and analyzing the nature and costs of goods and services that are provided to automobile accident victims by health care
providers;
• Preventing, detecting and suppressing fraud;
• Compiling anonymized statistics for government agencies; and
• Assessing underwriting risks and claims experience.

I ALSO UNDERSTAND that you, and persons acting for you, may disclose this information to the following persons or organizations, who may collect
and use this information only as reasonably necessary to enable you or them to carry out the purposes described above:

Insurers; insurance adjusters, agents and brokers; employers; health care providers; hospitals; accountants; financial advisors; solicitors; organizations
that consolidate claims and underwriting information for the insurance industry; fraud prevention organizations; other insurance companies; the police;
databases or registers used by the insurance industry to analyze and check information provided against existing information; and my agents or
representatives as designated by me from time to time.

I ALSO UNDERSTAND that you, and persons acting for you, may pool this information with information from other sources and may analyze this
information for the limited purpose of preventing, detecting or suppressing fraud.

I CONSENT to you collecting, using and disclosing information related to this Treatment and Assessment Plan in the manner described above, but no
more of such information than is reasonably necessary to meet the legitimate purpose of such collection, use or disclosure.

I UNDERSTAND that if I have any questions about this consent I am free to consult with my insurance company representative or legal advisor before
signing this document.

I AM ALSO AWARE that you, and persons acting for you, may be required or permitted by law to disclose this information to others without my
knowledge or consent.

I have reviewed and agree with this Treatment and Assessment Plan. I understand that payment for this Treatment and Assessment Plan is subject to
the approval of the insurer.

In the event that my insurer does not agree to pay for all the goods and services contemplated in this Treatment and Assessment Plan, I understand
that an examination may be required to determine my eligibility to the goods and services outlined in this Treatment and Assessment Plan.

In the event that an examination is requested, I authorize my insurer and my health care providers to give the person identified by the insurer to review
this application only such information relating to my health condition, treatment and rehabilitation received as a result of the accident, as is reasonably
required for the purposes of determining my eligibility to benefits.

As required by law, a copy of the examination report as well as the insurance company’s determination will be sent to me.

Subject to the Statutory Accident Benefits Schedule, in those circumstances where prior approval is required, I understand that if I undertake any of the
proposed services prior to approval by the insurer, I may be responsible for payment to my provider for any of the services rendered on my behalf.

I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT.

I UNDERSTAND THAT IT IS AN OFFENCE UNDER THE INSURANCE ACT to knowingly make a false or misleading statement or representation to
an insurer under a contract of insurance.

I FURTHER UNDERSTAND THAT IT IS AN OFFENCE UNDER THE FEDERAL CRIMINAL CODE for anyone, by deceit, falsehood, or other
dishonest act, to defraud or attempt to defraud an insurance company. This information will be used for processing payments of claims; identifying and
analysing the nature, effects and costs of goods and services that are provided to automobile accident victims, by health care providers; and
PREVENTING, DETECTING AND SUPPRESSING FRAUD.

To obtain further information about how your consent relates to pooling and data analytics to prevent and detect fraud please visit
http://www.ibc.ca/en/privacy-terminology.asp

To obtain further information about privacy related issues please contact the Privacy Officer at the insurance company listed in Part 2.

Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision Maker Date (YYYYMMDD)

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