PGD Document/=Auto Insurance Standard Invoice (OCF-21/59) Invoice Date year month day Facility Invoice Number/Reference Is this the first invoice for this claimant? Yes[] No[] Use of this form is for accidents that occur on or after November 1, 1996. This form applies to applicable medical and rehabilitation goods and services that are billed directly to an insurer by a health care provider or facility, or are included in a treatment plan, or are for the first 15 physiotherapy or chiropractic treatment sessions provided within 6 weeks of the accident. This form also applies to specified assessments, examinations, reports, treatment plans and attendant care provided by health care providers. Instructions on the completion of this form are set out in the User Manual available at www.standardinvoice.on.ca. Consent: It is the responsibility of the provider and the facility to ensure that the collection, use and disclosure of information submitted are authorized by a consent form or otherwise. Providers and facilities should use the Ontario Claims Form 5 (OCF-5) Permission to Disclose Health Information as a consent form. Part 1 Facility number GST number Facility Facility name (Biller) Address Information City Province Postal code Telephone number Extension Fax number Email address Facilities without a registration number may obtain one at www.aisiregistration.on.ca. This invoice is for: [] Treatment [] Insurer Examination [] DAC Services Check Type: [] Medical/Rehabilitation [] Disability [] Catastrophic [] Attendant Care [] Post 104 weeks [] Other Assessment Check Type: c Treatment Plan c Disability Certificate c Other Part 2 Date of birth Gender Claimant Last name Information First name Middle name Address City Province Postal code Is there an approved Treatment Plan (OCF-18) for this claimant? Yes [] No [] Waived by insurr [] If yes, date Treatment Plan signed by health practitioner Year Month Day Part 3 Company name City or town of branch office (if applicable) Automobile Adjuster (last name, name) Insurer Date of accident Policy number Information Claim number Name of policy holder: [] claimant, or Last name First name Part 4 Is there OHIP coverage for services billed on this invoice? [] Yes [] No [] Not applicable Other OTHER INSURANCE: Is there other insurance coverage for the billed services listed on this I have made reasonable enquiries of the claimant/patient and have determined that: Insurance There is other insurance coverage that is potentially [] NO There is no other insurance coverage for these services Information [] YES There is other insurance coverage that is potentially available to cover/partially cover these services.The details are expressed in this section of the invoice. NOTE: If this is a second or Other Other insurer name subsequent invoice, facilities do not have to Insurer Other insurer plan or policy number fill out Part 4, unless information has changed. 1 Name of the plan number Other insurer's identifier changed. Part 5 1 Last name First name Provider Information Profession/occupation College registration number or provider ID Part 6 Other injury and sequelae Codes Injury and 77 Injury description Injury Code (ICD-10-CA) Sequelae 78 Injury description Injury Code (ICD-10-CA) Information 79 Injury description Injury Code (ICD-10-CA) Part 7 Service Year Month Day Provider reference Number Injury Reference Number Pre- Authorized by Auto Insurer ? Times in minutes Hourly fee Net charge to OHIP/ Other insurer(s) Net charge to auto insurer(s) Information 1 Description [] Yes $ $ $ Service code [] No $ $ $ Year Month Day Provider reference Number Injury Reference Number Pre- Authorized by Auto Insurer ? Times in minutes Hourly fee Net charge to OHIP/ Other insurer(s) Net charge to auto insurer(s) 2 Description [] Yes $ $ $ Service code [] No $ $ $ Year Month Day Provider reference Number Injury Reference Number Pre- Authorized by Auto Insurer ? Times in minutes Hourly fee Net charge to OHIP/ Other insurer(s) Net charge to auto insurer(s) 3 Description [] Yes $ $ $ Service code [] No $ $ $ Subtotal Service Charges to Auto Insurer $ Part 8 1 Service reference # Other charges Number of km or per hour Rate per Km or per hour Amount Net charge to OHIP/Other insurer(s) Net charge t Auto-Insurer Other Charges [] Mileage []Travel time []Deburs. $ $ $ 2 Service reference # Other charges Number of km or per hour Rate per Km or per hour Amount Net charge to OHIP/Other insurer(s) Net charge t Auto-Insurer [] Mileage []Travel time []Deburs. $ $ $ 3 Service reference # Other charges Number of km or per hour Rate per Km or per hour Amount Net charge to OHIP/Other insurer(s) Net charge t Auto-Insurer [] Mileage []Travel time []Deburs. $ $ $ Part 9 1 Provider reference Number Description Amount Net charge to OHIP / Other insurer(s) Net charge to Auto-Insurer Supplies Supply code $ $ $ Provided To patient 2 Provider reference Number Description Amount Net charge to OHIP / Other insurer(s) Net charge to Auto-Insurer Supply code $ $ $ 3 Provider reference Number Description Amount Net charge to OHIP / Other insurer(s) Net charge to Auto-Insurer Supply code $ $ $ Subtotal Supply Charges to Auto Insurer $ Subtotal Service Charges to Auto Insurer (Part 7) $ Subtotal Other Charges to Auto Insurer (Part 8) $ Subtotal Supply Charges to Auto Insurer (Part 9) $ Total charges to Auto Insurer (Part 7+Part 8+Part 9) $ Goods and Services Tax (GST) $ PST on goods (if applicable) $ Grand total $ Prior outstanding Balance As of Year Month Day $ Part 10 Is this a final invoice [ ] Yes [ ] No Other Information Comments Facility I certify that the expenses submitted and described above are true and accurate and are required as a direct result of the accident. Signatory Print name Signature TI ( @P! @P-@P. @P:@P;@P<@P@@PB@PG@PI@PL@PO@PP!@Pq@Pr@Pt,@P@P @P@P@P. @P7@P1*@P[@P n@P o@Pu@Pw@P@P @P@P @P@P @P@P @P@P@P@P  @P@P@P@P@P@P @P"@P6@PF@PV @P_@Pa @Pk@P{ @P@P@P U@P@P @P @P  @P @P @P *@P - @P:@PI@PJ[@P @P @P @P @P@P @P@P @P@P@P@P @P@P @P @P"@P(@P 7@P?@PA @PJ@P ^ @Pi@Pk @Pu@P@P@P@P@P@P@P @P@P@P@P @P@P @P @P-@P @P # @P- @P/ @PI @P e @Pl @Pn @P~ @P @P @P @P @P @P C@P @P! @P# @P- @P 0 @P6 @P8 <@P t @P w @P { @P ~ @P @P @P @P @P @P @P @PI @P J @PS @P U 6@P @P @P @P 8@P @P @P @P @P @P @P @P 5@P @P  k@P @P @P @P @P @P @P @P @P -@P @P @P @P #@P @P  1@PG @PK @PO @PP @PR @PS @Pb @Pc @P} @P  @P @P @P @P @P @P @P @P @P @P @P @P *@P@P @P$@P 2 @P<@PA@PS@PT@Pk@P m@Pu@Pz@P@P@P@P  @P@P@P@P@P @P@P @P@P  @P@P@P@P@P@P@P@P @P@P@P@P@P@P@P@P @P @P@P@P@P@P@P@P@P@P@P@P (@PH@P L@PR@PT@PU@PV@P @P@P#@P" @P,@P-@P.@P @P@P#@P @P@P@P@P @P@P#@P @P @P@Pn@P ;@PC@P Y@Pm@Pp@P@PT@P@P@P@PT@Pf@P|@P}@P~'@P@P@P@P1@P@P/@P@P0@PB@PF4@Pz@P~@P@P@P@P @P@P @P@P @P @P @P$@P 3@PD@PF@PN@P R@PZ@P[@P@P  @P@P @P@P @P@P"Arial"Arial8"Arial"Arial8"Arial"Arial81Courier New8"Arial"Arial"Arialt"Arialt"ArialL1Courier New"Arial"ArialV"ArialV"ArialV1Courier Newt"ArialL"Arial"Arial"ArialL"Arial$"Arial,--.:;;<@AABGHHILMNOOPqrrsst,--.mnnouvvw"#344556FGUV_``aklxyyzz{)*FG !"()67?@@AJK]^ijjkuv;<]^  " # - . . / I J d e l m m n ~              ! " " # - . . / / 0 6 7 7 8     I J S T T U                   G H H I J K b c } ~ ~                    /00112<==>@ASTkllmuvvwyz  $%56<=ABLM^_opz{{|       89IJPQUV`ars #$'(ABRSYZ^_ij{| HIJKKLRSSTUVijwx  !""##$%&'()**++,-.ABOPhi 45LMSTwx :;CDDEEFFGRSTUVWXYablmmnop$%JKeffgghhiijuvwxyz{||}}~BCDEEFz{|}}~    #$+,2389DEEFNOOPPQQRZ[d nJ &p#'L,0(59>dp@ P !$`'d nJ &p#'L,0(59>d nJ &p#'L,0(59>dp@ P !$`'d nJ &p#'L,0(59>d nJ &p#'L,0(59>--.;<ABHIN OOPrsstOmOAoulvvlwi  lli 'lli 'lli s 3} 44l55l6Ui V`t ax yylzzl{i 'llM Cll!i "6 7?l@@lA]M C^iljjlkM  M M CM M  c y M ]M  ^    ! llM "  # - l. . l/ d M Ce l lm m ln M   l l M C M   M   " c # . y 0 6 l7 7 l8 0 ` l l I 0 ` J S lT T lU 0 ` l l 0 ` l l 0   l l 0    G H H  I J 0 K b c ~   0  0 ` l l D \ t  |  l l D \ t |  /0 ~ 00< 11 2< == >@0 TAS Tl  mu vv wy0 T z     0 T     p } }} } $}%<}=^_owp{ w|w! p p    u   o p r ! p p  uop  r  !    p } }}}8}9P}Qrsw ww! p p    u   o p r ! p p  u op r !   p } }#}$'}(A}BY}Z{|w ww! p p    u   o p r ! p p  uop r ! 0  H0 IJ  LRlSSlTU0 kVi kjwkxqkkGkk!sll0 k k!k""qk##k$%Gk&'k()!s**l++l,-0 k.A kBOkPhqkikGkk!sll0 k kkqkkGkk!sll0 k  kk4qk5LkMSGkTwkx!sll0 k kkqkkGkk!sOO  Sg S  77 :> R;CO DDO EE S FFg S GR  ST7 UV7 WX> R YlO mmO no Spg S  77> RO O  S g S   7 7 > R O O  Sg S  $7%J7Ke> RffO ggO hh S iig S ju  vw7 xy7 z{> R }}0 ~0    r  r B CDrEE Fz {|r}} ~ r  r  r  zr l  l #D $+ J ,2=S 3Dl EEl FND OO DPP7"YRZ0 [0 `0 0  PPPPP P PP P PPPPPPPPPPPPPPPPPPPPPPArialArialArialArialArialArialCourier NewArialArialArialArialArialCourier NewArialArialArialArialCourier NewArialArialArialArialArialArial