PGD Document/=9 Treatment Plan (OCF-18/59) Use this form for accidents that occur on or after November 1st, 1996. In order to qualify for payment of medical and rehabilitation expenses, a health practitioner (e.g. physician, psychologist, physiotherapist, dentist, optometrist, chiropractor) must approve your treatment plan. An insurer may agree to pay for expenses without the submission of a treatment plan. This treatment plan must be prepared and supervised by a regulated health professional. Please complete Part 1 and give the form to your health practitioner. Part 1 Last name First name Application Address Date of accident Information City Province Postal code Phone number Part 2 Parts 2 and 3 must be completed by the Health Practitioner who is approving this Treatment Plan Impairment \Disability Impairment Description If there is a whiplash-associated disorder, please indicate grade (See Part 11) Injury Codes See Part 10 Body Part Nature of injury 1 2 3 4 Disability resulting from impairment caused by the automobile accident (Describe) Estimated duration of disability From To Part 3 Signature Name of Health practitioner Health profession/specialty Address City Province Postal code Facility Telephone number Fax number I certify that this treatment Plan is reasonable and necessary for the treatment and the rehabilitation of the insured person Signature of the service provider Date Part 4 Parts 4 through 9 must be completed by the Regulated Health Professional who is preparing this Treatment Plan Treatment Plan Goal Short term goals of Treatment Plan Long term goals of Treatment Plan At the end of Treatment Plan, is there an anticipated charge for disability Yes return to Work Caregiver duties Activities of normal life school No Part 5 Plan supervision Name of the regulated health professional Registration number You are a Address City Province Postal code Facility Telephone number Fax number Part 6 List separately each element to be provided under this Treatment Plan(Attach additional copies if needed) Treatment Plan Description of good/service Procedure code Description of anticipated benefits (indicate which impairments listed in part 2 are being addressed by good /service Estimation of how long and how often good/service will be provided Estimated cost $ Code Name of Health practitioner Health profession/specialty Address City Province Postal code Facility Telephone number Fax number Part 7 Plan preparation Name of the regulated health professional Registration number You are a Address City Province Postal code Facility Telephone number Fax number Part 8 The health professional identified in Part 7 who is responsible for preparing the Treatment Plan must complete the following Conflict of interest Statement Conflict of Interest Statement Conflict of Interest Statement A person has a conflict of interest relating to a treatment plan if: (i)The person or a member of the person's family may receive a financial benefit, directly or indirectly, as a result of the provision, by a member of the person's family or another person, of goods or services contemplated by the treatment plan, and (ii) The person who may receive the financial benefits is not the employee of the person who will provide the goods or services and does not have a contract with the person who will provide the goods and services under which goods or services of that kind are provided. I wish to declare that I have no conflicts of interest relating to this Treatment Plan I have determined, after making reasonable inquiries, that there are no conflicts of interest on the part of any person who referred the applicant with respect to a person on who will provide goods or services contemplated by this Treatment Plan. I am declaring the following conflicts of interest relating to this Treatment Plan: Note: After approving this Treatment Plan, if the insurer determines that there was a conflict of interest that was not disclosed the insurer may give the applicant notice to amend the Treatment Plan to remove the conflict of Interest and if no amendment is made, the insured is not required to pay for any further expenses for which there is a conflict. 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