worker’s compensation board - brooks, ab chiropractic€¦ · the chiropractic physician is...
TRANSCRIPT
Box 1570, 212 2nd Ave West Brooks, AB T1R 1C4
Ph: 403-793-8484 Fax: 403-793-8483
________________________________________________________________________________________
Dear Patient,
Thank you for choosing Soft Health and Healing Clinic as your health care provider for your Worker’s Compensation
Board (WCB) claim. We look forward to providing you with top notch, state-of-the-art care.
There are a few things you must accomplish before beginning treatment at Soft Health and Healing Clinic:
1. You must report the injury as soon as possible to your employer. He/she will send an “Employer Report of Injury”
form to WCB within 72 hours.
2. You must also see your family physician regarding your injury. He/she will complete a “Physician’s Injury Report”
and send it to WCB within 48 hours.
3. Complete a “Worker’s Report of Injury” if you have a permanent injury, need medical treatment or are off work. Send
your report to the WCB.
WCB will register your compensation benefits upon receiving all of these reports. You will then have a representative
assigned to your claim. Please make sure that the information you provide is as detailed and complete as possible as this
will help for a timely decision on your claim.
In order to receive treatment at Soft Health and Healing Clinic you will be required to sign a WCB contract explaining
that you are responsible for the costs of your treatments should the WCB deny your claim.
Coverage through WCB entitles you to one treatment per day, up to a twenty-two (22) treatment maximum, over a 6 week
period. A soft tissue session counts as one (1) treatment, and a low intensity laser therapy session also counts as one (1)
treatment. We will contact the WCB requesting more care if the Doctor feels it is necessary.
Please read through the information provided and fill out all attached questionnaires. Remember that the more
information we have, the better we can diagnose and treat your condition. Please make sure to note anything you have
noticed leading up to and/or after the injury, no matter how insignificant it may seem.
Yours in Health,
Soft Health and Healing Clinic
Worker’s Compensation Board – Intake Forms
Personal Information:
First Name __________________ Middle Initial _____ Last Name ______________________
Alberta Health Care # ________________ Date of Birth _______________ Male / Female
Address ___________________________ City ___________________ Province _____
Postal Code ________________ E-mail ________________________
Ph# (home) ________________ Ph# (work) _______________ Ph# (cell) ________________
WCB Claim # _________________ Claims Rep. Name _________________ Ph# ____________
Work information:
Job Title: ________________________________________
Employer Name: _______________________________________________________________
Company Ph: ( ) _______________________________ Ext. _________
Address: ______________________________________________________________________
City: _______________________ Province: _________ Postal Code: ______________________
Injury Information:
Date of Injury (YYYY/MM/DD): _____________ Date of First Treatment (YYYY/MM/DD): ____________
Describe, fully, what you believe caused your condition. Please include any relevant past history.
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________
Area(s) of Injury/Disease:
O Ankle O Arm O Back O Brain O Elbow O Face O Fingers
O Foot O Hand O Head O Knee O Leg O Non-personal O Shoulder
O Systems O Teeth O Trunk O Unknown O Wrist
Side of the Body: O Right O Left O Both Sides
Have you had the same or similar complaint before?
O Never O 2 times O 4 times O Multiple times O 1 time O 3 times O > 4 times
Has the problem been getting better or worse since the onset?
O Improving O Getting worse O Comes and goes O Stayed about the same
What limitations have you experienced as a result of your injury? (choose all that apply and
circle capabilities)
O Sitting Able Unable Limited to ___ O Climbing Able Unable Limited to ___
O Standing Able Unable Limited to ___ O Pushing/Pulling Able Unable Limited to ___
O Walking Able Unable Limited to ___ O Overhead reaching Able Unable Limited to ___
O Bending Able Unable Limited to ___ O Driving Able Unable Limited to ___
O Twisting Able Unable Limited to ___ O Lifting Able Unable Limited to ___
O Kneeling/squatting Able Unable Limited to ___
Describe how this injury affects your job requirements:
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________
Have you missed any work as a result of your condition?
O Yes - If yes, how many days did you miss? __________ days. O No
Have you returned to work? O Yes O No
Current work status: O Yes – full duties O Yes – modified duties
O Yes – alternate duties O No – not working at all
Is modified work available? O Yes – it is available and I can perform the required tasks
O Yes – it is available but I cannot perform the required tasks O No – it is not available/possible
Are you working Modified hours? O Yes O No
If not working do you have a job to return to? O Yes O No
Your last full day of work was (YYYY/MM/DD)? ______________________
Are you currently receiving worker’s compensation? O Yes O No
List your surgical and hospitalisation history.
Past Surgical History
Date: ____________________
Where: _______________________________
Type of Surgery: ________________________
Surgeon: ______________________________
Complications/remaining problems:
______________________________________
Past Hospitalisations
Date: ______________________
Cause of Hospitalisation: __________________
___________________________________________
___________________________________________
Complications/remaining problems:
______________________________________
List your previous medical treatment and diagnostic tests. For example: Plain X-rays / CT Scan / MRI / EMG / Myelogram / Discogram / Thermogram / Bone Scan / Blood & Urine Chemistries / Other
Type of Test:
Date (approx):
Hospital/facility name:
Area of Body:
List your current medications, both prescription and non-prescription:
1. ______________________________ 4. ______________________________
2. ______________________________ 5. ______________________________
3. ______________________________ 6. ______________________________
Health History Questionnaire
Have you ever been diagnosed or told you have any of the following: Circle the correct response.
1. High Blood Pressure? Yes/No
2. Hardening of the arteries (arteriosclerosis)? Yes/No
3. Diabetes? Yes/No
4. Tuberculosis? Yes/No
5. Cancer? Yes/No
6. Heart or blood diseases? Yes/No
7. Bone spurs on the neck? Yes/No
8. Whiplash injury? Yes/No
9. Have you or any of your relatives ever suffered a stroke? Yes/No
10. Were you ever a Smoker? Yes/No
From _________________________ To _______________________ 11. Do you take medication on a regular basis? Yes/No
12. Visual disturbances (blurring, loss, double vision)? Yes/No
13. Hearing disturbances (loss, ringing, other noise)? Yes/No
14. Slurred speech or other speech problems? Yes/No
15. Difficulty swallowing? Yes/No
16. Dizziness? Yes/No
17. Loss of consciousness, even momentary blackouts? Yes/No
18. Numbness, loss of sensation, loss of strength or weakness in the face, fingers, hands, arms, legs, or any other
parts of the body? Yes/No
19. Sudden collapse without loss of consciousness? Yes/No
20. Back pain/Leg Pain Yes/No
21. Neck pain/Arm Pain Yes/No
22. Depression, Anxiety, etc. Yes/No
23. Recent international travel Yes/No
Please explain any “Yes” answers above:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Systems Review
Circle any conditions that are presently causing you a problem. Underline those that have caused you problems in the past.
GENERAL SYMPTOMS RESPIRATORY GENITOURINARY
Fever Sweats Fainting Sleep disturbance Fatigue Nervousness Weight loss Weight gain
Chronic cough Spitting up phlegm Spitting up blood Chest pain Wheezing Difficulty breathing Asthma
Frequent urination Painful urination Blood in urine Pus in urine Kidney infection Prostate trouble Uncontrollable urine flow
NEUROLOGICAL CARDIOVASCULAR GASTROINTESTINAL
Visual disturbance Dizziness Fainting Convulsions Headache Numbness Neuralgia (nerve pain) Poor coordination Weakness
Rapid beating heart Slow beating heart High blood pressure Low blood pressure Pain over heart Hardening of arteries Swollen ankles Poor circulation Palpitations Cold hand or feet Varicose veins
Poor appetite Difficult digestion Heartburn Ulcers Nausea Vomiting Constipation Diarrhea Blood in stool Gallbladder/jaundice Colitis
EYES, EARS, NOSE, THROAT MUSCLE & JOINT FOR WOMEN ONLY
Eye pain Double vision Ringing in ears Deafness Nosebleeds Trouble swallowing Hoarseness Sinus infection Nasal drainage Enlarged glands
Neck pain Low back pain Arm pain Shoulder pain Leg pain Knee pain Foot pain Pain/numbness down arms or legs Pain between shoulders swollen joints Spinal curvature Arthritis Fractures
Painful menstruation Hot flashes Irregular cycle Cramps or back pain Vaginal discharge Nipple discharge Lumps in breast Menopausal symptoms Birth control pills Miscarriages Complications with pregnancy Pregnant? Y / N Week? Other:
Pain Drawing
Activities Discomfort Scale
Box 1570, 212 2
nd Ave West
Brooks, AB T1R 1C4
Ph: 403-793-8484 Fax: 403-793-8483
_____________________________________________________________________________________
Worker’s Compensation Board Contractual Agreement
1. I understand that Soft Health and Healing Clinic has agreed to provide chiropractic services
and will not require payment until my claim has been approved by WCB, after which time Soft Health and Healing Clinic will bill WCB directly.
2. I understand that if I am not approved by the WCB, that I am liable for any and all charges
incurred for services provided to me by Soft Health and Healing Clinic
3. In the event that the WCB denies my approval after already having approved it, I understand that I will be responsible for payment of fees from the date of denial forward.
4. I understand that Soft Health and Healing Clinic has a cancellation policy in place, wherein
any appointment missed or cancelled within 24 hours is subject to a cancellation fee equal to the treatment fee. I further understand that I, not WCB, am responsible for payment of any cancellation fees.
5. I understand that if I cancel or fail to show up for three consecutive appointments (without
explanation within twenty four [24] hours) that Soft Health and Healing Clinic will automatically suspend my treatments and notify my case worker. Soft Health and Healing Clinic will not arrange extra treatments to make up for such absences.
6. I understand that my initial treatment protocol period is six (6) consecutive calendar weeks
with a maximum of twenty two (22) treatments available and that only one (1) treatment can be performed and billed to WCB per day.
_____________________________ __________________________________ Patient Name (Printed) Patient Signature _____________________________ __________________________________ Date Witness to Above Signature
Visa MC Amex _ _____________________________ Credit Card # Expiry
Cancellation Policy
Purpose
The purpose of this policy is to encourage awareness that missed appointments have an impact on the
physician’s, therapists’ and patients’ schedules. Arranging appointments according to prescribed treatment
plans assists both patient and practitioner in achieving optimal healing goals in a quicker timeframe.
Policy
Soft Health and Healing Clinic requires 24 hours notice if an appointment is to be missed. Less than 24 hours notice will result in a cancellation fee of $40.
Thank you for your understanding.
THE “50% RULE”
The chiropractic physician is seeking 50% relief of pain (measured subjectively and objectively)
within 30 days of care.
TYPICAL PATIENT OUTCOMES
Median number of days to maximum improvement: 29
Median number of visits to maximum improvement: 12
OFFICE USE ONLY
Claim #: AHC#:
Adjustor’s Name:
Adjustor’s Phone#:
Date of Injury:
Exam Date:
Chiropractic First Report Submission Date:
Progress Report Date:
Treatment Extension Request Date:
Discharge Date:
Notes: