WSIB Form 8 "Health Professional's Report" - Ontario, Canada

What Is WSIB Form 8?

WSIB Form 8, Health Professional's Report, is used by health practitioners to record a person's injuries that occurred at work.

Alternate Name:

  • WSIB Claim Form 8.

This form is issued by the Ontario Workplace Safety and Insurance Board (WSIB) and was last updated August 1, 2011. A fillable WSIB Form 8 is available for download through the link below.

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WSIB Form 8 Instructions

To complete WSIB Form 8 you will need to include the following information for a patient:

  1. Page 1 requires general information of the patient (name, address, sex, telephone, social insurance number, date of birth) and the name of the employer.
  2. Provide a brief description of how the injury occurred during work, when symptoms began, and the patient's job title.
  3. Identify all areas of the patient's body that were impacted by the injury based on the checklist, as well as the checklist describing the type of injury, recording the patient's pain rating, and any possible exposure the patient may have gone through that could negatively impact their health (such as from chemical fumes or exposure to poisons). Include any preexisting conditions the patient had before the accident occurred and your diagnosis based on the symptoms presented by the examination.
  4. Describe what you advise as to the course of treatment for the patient, how long treatment should take, and the medication you will be prescribing. If you are a physician you will need to include on Form 8 the name of the medications, dosage, length of time the medication should be taken for, and how often the patient will need to be taking the medication.
  5. You can also recommend additional examinations such as X-Rays, CT scans, or visits to an occupational therapist as part of your recommendations.
  6. Finalize the billing information section with your health professional occupation title, amount to be billed, invoice information, and your office's contact information.
  7. Page 2 details the conversation you had with the patient about whether or not they can expect to return to work and when, if the injury will result in any reduced capacity to perform their essential job duties, and if you will require future visits to assess the patient's recovery progress.
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Health Professional's Report (Form 8)
Health Professional, please use this form for:
Patients who are claiming benefits under the WSIB insurance plan for an injury/illness
λ
related to work, or
You think that the cause of your patient's injury/illness is workplace factors.
λ
Section 37 of the Workplace Safety and Insurance Act, 1997 provides the legal authority for health
professionals, hospitals and health facilities to submit, without consent, information relating to a worker
claiming benefits to the Workplace Safety and Insurance Board (WSIB).
Completing the form:
Give a copy of page two only to your patient to give to employer.
λ
Please send pages one and two to the Workplace Safety and
λ
Insurance Board.
On the worker's initial visit, ONLY the Form 8 will be paid. A Functional
λ
Abilities Form (FAF) will not be paid if completed on the same date.
For Electronic Submission
To register for electronic form submission and electronic billing, please go to www.telushealth.com/wsib or call
Telus at 1-866-240-7492 for more information.
By Fax to:
416-344-4684 or 1-888-313-7373
Or by Mail to:
Workplace Safety and Insurance Board
200 Front Street West
Toronto, ON M5V 3J1
www.wsib.on.ca
0008A1
Health Professional's Report (Form 8)
Health Professional, please use this form for:
Patients who are claiming benefits under the WSIB insurance plan for an injury/illness
λ
related to work, or
You think that the cause of your patient's injury/illness is workplace factors.
λ
Section 37 of the Workplace Safety and Insurance Act, 1997 provides the legal authority for health
professionals, hospitals and health facilities to submit, without consent, information relating to a worker
claiming benefits to the Workplace Safety and Insurance Board (WSIB).
Completing the form:
Give a copy of page two only to your patient to give to employer.
λ
Please send pages one and two to the Workplace Safety and
λ
Insurance Board.
On the worker's initial visit, ONLY the Form 8 will be paid. A Functional
λ
Abilities Form (FAF) will not be paid if completed on the same date.
For Electronic Submission
To register for electronic form submission and electronic billing, please go to www.telushealth.com/wsib or call
Telus at 1-866-240-7492 for more information.
By Fax to:
416-344-4684 or 1-888-313-7373
Or by Mail to:
Workplace Safety and Insurance Board
200 Front Street West
Toronto, ON M5V 3J1
www.wsib.on.ca
0008A1
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8
Fax To:
Claim Number (If known)
Health Professional's Report
416-344-4684
(Form 8)
OR 1-888-313-7373
Start >
A. Patient and Employer Information
- (Patient to complete Section A)
Init.
Sex
First Name
Last Name
M
F
City/Town
Prov.
Postal Code
Address (no., street, apt.)
ON
Language
Date of
dd
mm
yyyy
Telephone
Social Insurance No.
Birth
Eng.
Fr.
Other
Employer Name
The Workplace Safety and Insurance Board (WSIB) collects your information to administer and enforce the Workplace Safety and Insurance Act. The Social Insurance Number may be used to identify workers
and to issue income tax information statements as authorized by the Income Tax Act. Questions should be directed to the decision maker responsible for your file or toll free at 1-800-387-5540.
B. Incident Dates and Details Section
Occupation
1. How did the injury/reinjury or illness occur at work?
dd
mm
yyyy
Date of incident/or when
did the symptoms start?
C. Clinical Information Section
- (Please check all that apply)
1.
Area of Injury/Illness
Right
Right
Left
Right
Left
Left
Right
Left
Brain
Ears
Wrist
Hip
Ankle
Upper back
Shoulder
Head
Teeth
Arm
Thigh
Foot
Hand
Lower back
Face
Neck
Abdomen
Elbow
Knee
Fingers
Toes
Eyes
Chest
Pelvis
Forearm
Lower Leg
Other:
2.
Pain Rating Scale
Description of Injury/Illness Physical Examination Findings
Exposure/Illness
Pain at rest/Night Pain
Asthma
0
1
2
3
4
5
6
7
8
9
10
Repetitive Strain Injury
Cancer
Abrasion
Disc Herniation
Inflammation
Spinal Cord Injury
Fumes - Inhalation
Amputation
Dislocation
Internal Joint Derangement
Hand-arm Vibration
Sprain/Strain
Bite
Joint Effusion
Fall from Height
Hearing Loss
Burn
Foreign Body
Laceration
Surgical Intervention
Tendonitis/Tenosynovitis
Infectious Disease
Contusion/Hematoma/Swelling
Fracture
Neurological Dysfunction
Range of Motion
Needle Stick
Crush Injury
Hernia
Psychological
Poisoning/Toxic Effects
Infection
Puncture (non-needlestick)
Skin Condition
Other
3.
Are you aware of any pre-existing or other conditions/factors that may
4.
Diagnosis
impact recovery?
yes
no
If yes, describe
D. Treatment Plan
1.
What is the treatment plan (type of treatment, duration) including prescribed medications?
2.
To be completed by physicians only.
Work Injury/Illness Medications
Dose
Frequency
Duration
Work Injury/Illness Medications
Dose
Frequency
Duration
1.
3.
2.
4.
3.
Investigations & Referrals:
Ultrasound
None
Labs
Xrays
CT Scan
MRI
EMG
Other
Would the patient benefit from the
FP/GP
Occupational Health Centre
Physiotherapist
following referrals?
Specialist/
Occupational Therapist
Psychologist
Specialty Clinic
Specialty
Chiropractor
Other
Regional Evaluation Centre (REC)
Name of Referral or Facility (if known)
Telephone
dd
mm
yyyy
Appointment
Date
E. Billing Section
Service Code WSIB Provider ID
Health Professional Designation
Chiropractor
Physician
Physiotherapist
Registered Nurse (Extended Class)
8M
HST Registration No.
HST Amount Billed (if applicable)
Service Code
Your Invoice No.
Service Date
dd
mm
yyyy
ONHST
$
Health Professional Name (please print)
Address
Fax
Telephone
Page 1/2
0008A (08/11)
visit our website at:
www.wsib.on.ca
8
Health Professional's Report
Claim Number (If known)
(Form 8)
Return To Work Information
Once completed, please ensure that a copy of this page only is provided to the worker.
dd
mm
yyyy
Last Name
First Name
Init.
Birth
Date
Area(s) of Injury(ies)/Illness(es)
dd
mm
yyyy
Date of
Incident
F. Return To Work Information - Must be completed by a Health Professional
When work injury/illness occurs, focus on return to usual activity including return to safe and appropriate work is best
practice. Most workers who experience soft tissue injury are able to remain at work.
1.
yes
no
Have you discussed return to work with your patient?
dd
mm
yyyy
2.
This worker can resume Regular duties. Start date
If graduated hours required please specify
dd
mm
yyyy
If graduated hours required please specify
This worker can begin Modified duties. Start date
This worker is not able to work because of the workplace injury/illness.
Please provide explanation
3. Please indicate the worker's status and functional abilities in relation to the workplace injury and diagnosis.
A. Full Functional Abilities
Able to
Not Able to
Able to
Not Able to
Able to
Not Able to
B. Worker Functional
Stand
Bend/Twist
Operate Heavy Equipment
Abilities
Climb
Use of Public Transportation
Operate a Motor Vehicle
Kneel
Use of Upper Extremities
Push/Pull
Lift
Sit
Walk
eg. Environmental Conditions, Medication, Use of Protective Equipment.
C. Other Limitations:
Please describe:
4.
From the date of this assessment, the above limitations will
5. Follow-up Appointment
apply for approximately:
dd
mm
yyyy
Date of next
None
1 - 2 days
3 - 7 days
8 - 14 days
14 + days
As Needed
required
appointment
Address
Health Professional's Name (Please print)
Health Professional's Signature
Telephone
dd
mm
yyyy
Service Date
PLEASE PRINT AND SIGN
G. Worker's Signature
By signing below I am authorizing the above noted health professional, who is treating me, to provide my employer with a copy of this page outlining my functional abilities. I understand a
copy will be sent to the Workplace Safety and Insurance Board (WSIB) by my health professional.
dd
mm
yyyy
Signature
Date
PLEASE PRINT AND SIGN
Once completed, please ensure that a copy of this page only is provided to the worker.
0008A
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