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Disability Certificate (OCF-3)

USE THIS FORM FOR ACCIDENTS THAT OCCUR ON OR AFTER NOVEMBER 1,1996.

Claim Number:

Policy Number:

Date of Accident:

(YYYYMMDD)

For this applicant, this is Disability Certificate number _______ from this health professional/facility

Use this form for accidents that occur on or after November 1, 1996. If your insurance company asks you to complete this form, fill out Parts 1 to 3 and give the form to your health practitioner (chiropractor, dentist, nurse practitioner, occupational therapist, optometrist, physician, physiotherapist, psychologist, speech language pathologist). After your health practitioner has explained your accident-related injury to you, sign Part 4. Your health practitioner will complete the rest of the form, based on his/her most recent assessment, and return it to the insurance company. Your health practitioner must forward the form to the insurance company within 21 days of your company sending this form to you or within 14 days of your insurance company notifying you that they intend to discontinue your benefits. Only an authorized health practitioner can complete this form. The health practitioner’s opinion will be relied upon by people who review the certificate to make important decisions. Accordingly, it is necessary to be accurate and complete. Please print clearly and provide all information requested. This form may not be materially altered.

Confidentiality: Collection, use and disclosure of this information is subject to all applicable privacy legislation.

	Date Of Birth (YYYYMMDD)		Gender				Telephone Number	Extension
	Date Of Birth (YYYYMMDD)		Gender				Telephone Number	Extension
Part 1			ｒ Male	ｒ Female

	Last Name
Applicant	Last Name
Applicant
Information
Information	First Name				Middle Name
To be completed by
To be completed by	Address
the applicant	Address
the applicant

	City		Province				Postal Code
							__


	Name of Insurance Company					City or Town of Branch Office (if applicable)
Part 2
Part 2	Name of Insurance Company Representative:
Insurance	Name of Insurance Company Representative:
Insurance
Company
Company	Adjuster Telephone					Adjuster Fax
Information

	Name of policy holder same as:	Policy Holder Last Name				Policy Holder First Name
To be completed by	ｒ Applicant OR
the applicant

Part 3

Accident

Description

To be completed by the applicant

Give a brief description of the accident and what happened to you. Please describe any injuries you sustained as a direct result of the accident.

ｒ additional sheets attached

OCF-3 (11/04) Page 1 of 5

		I authorize my treating health professional to collect, use and disclose to my insurer, any information relating to my health condition and
	Part 4	treatment received as a result of the automobile accident and any pre-existing or subsequently occurring health conditions that may be
	Part 4	barriers to my recovery as a result of the automobile accident, for the purpose of providing treatment and determining my eligibility for
	Applicant
	Applicant	benefits. This authorization is valid until my claim for Statutory Accident Benefits has been concluded.
	Signature	I authorize the health practitioner who completes this form to contact my employer, if this is necessary, to confirm the essential tasks of
		my employment and the nature and extent of any available work with modified hours or duties.
		TO THE INSURER:
		TO THE INSURER:
		I UNDERSTAND that you, and persons acting for you, will collect and use personal information and personal health information about
		me that is related to my claims for accident benefits arising out of the accident described in my application.
		I ALSO UNDERSTAND that this information will be collected, used and disclosed for the purposes of:

•Investigating 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;

•Identifying and analyzing the nature, effects and costs of goods and services that are provided to automobile accident victims by health care providers;

•Preventing and detecting fraud;

•Compiling anonymized statistics for government agencies;

•Assessing underwriting risks and claims experience; and

•Allowing you to comply with your legal obligations to others, such as government regulators, auditors and reinsurers.

I ALSO UNDERSTAND that you, and persons acting for you, may disclose this information to the following persons, who may collect and use this information for the purposes described above:

•Insurers; reinsurers; insurance adjusters, agents and brokers; employers; health care professionals; hospitals; accountants; financial advisors; solicitors; federal, provincial or municipal governments and agencies where required or authorized by law; police forces or law enforcement agencies; and my agents or representatives;

•Organizations designated as investigative bodies under privacy laws;

•Claims processing agencies and statistical analysis organizations to whom you are directed by law to disclose claims, payment requests and other claims information; and

•Organizations that consolidate claims and underwriting information for the insurance industry.

I CONSENT to you collecting, using and disclosing this information in the manner described above.

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.

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

To the Health Practitioner:

Please complete the following information based on your most recent examination of the applicant named in Part 1 and return the form to the insurance company listed in Part 2. Please print clearly.

Part 5

Injury and

Sequelae

Information

This part and the rest of this form must be completed by your Health Practitioner

Provide a description (list most significant first) and associated ICD-10-CA+ code for any injuries and sequelae that are the direct result of the automobile accident.

Description	Code

Note+:Refer to the User manual at www.autoinsurancereforms.on.ca for ICD-10-CA coding information.

OCF-3 (11/04) Page 2 of 5

Date symptoms first appeared: (YYYYMMDD)

Date of most recent examination: (YYYYMMDD)

Part 6

Relevant

Dates

Date of first post-accident examination: (YYYYMMDD)

(a) Applicant was seen by me prior to the accident. Yes

(b) If answer to (a) is yes, enter date on which applicant was first seen:

______________________________________

Part 7 Disability Tests and Information

a) Based on your current knowledge and information provided by the applicant, please provide a response to each Benefit/Applicant Category

Benefit/Applicant

Disability Test

Onset of

Task/Activity Limitations

Anticipated

Disability

Category

Duration

(YYYYMMDD)

As the Primary Caregiver, does the

Please explain:

applicant suffer a substantial inability to

engage in the caregiving activities in

which he/she engaged at the time of the

accident? (Primary Caregiver means

that, at the time of the accident, the

applicant was residing with a person in

ｒ 1-4 weeks

need of care and the applicant was the

ｒ 5-8 weeks

primary caregiver for the person in need

Caregiver Benefits

ｒ 9-12 weeks

of care and did not receive any

ｒ more than 12

remuneration for engaging in caregiver

weeks

activities.)

ｒ Yes

ｒ No

ｒ N/A

Is the applicant, as a result of the

Please explain:.

accident, unable to continue in an

elementary, secondary, post-secondary

or continuing education program that the

ｒ 1-4 weeks

applicant was enrolled in at the time of

ｒ 5-8 weeks

Lost Educational

the accident ?

ｒ 9-12 weeks

Expenses

ｒ Yes

ｒ No

ｒ N/A

ｒ more than 12

weeks

Does the applicant suffer a substantial

Please explain:

inability to perform the housekeeping and

home maintenance services that he/she

normally performed before the accident?

ｒ 1-4 weeks

Housekeeping and

ｒ Yes

ｒ No

ｒ N/A

ｒ 5-8 weeks

Home Maintenance

ｒ 9-12 weeks

Expenses

ｒ more than 12

weeks

b) If you responded Anticipated Duration ‘more than 12 weeks’ to any disability test above, please explain why the task/activity limitations are likely to persist beyond 12 weeks.

Part 8

Further Investigations or Consultations

a)Have there been any examinations, investigations, or consultations not previously reported by you?

ｒNo ｒ Yes (please specify findings and results)

b)Are further examinations, investigations or consultations contemplated or required?

ｒNo ｒ Yes (please specify)

OCF-3 (11/04) Page 4 of 5

Yes (please explain)

Part 9

Prior and

Concurrent

Conditions

Part 10 Medications

a)Prior to the accident, did the applicant have any disease, condition or injury that affected his/her ability to perform the activities listed in Part 7?

ｒ No ｒ Unknown ｒ

If yes, is the applicant currently receiving any disability benefits for the pre-existing disease, condition or injury?

ｒ No

ｒ Unknown

ｒ Yes (please explain)

If you treated the applicant for similar conditions prior to the accident, please describe (include date of onset, any subsequent interventions, and status at the time of the accident).

b)Since the automobile accident, has the applicant developed any disease, condition or injury, not related to the accident, that could affect his/her disability?

ｒ No

ｒ Unknown

ｒ Yes (please explain)

a)Please list any medications (including dosage and frequency) that the applicant is currently taking for injuries related to the automobile accident.

Were these medications prescribed by you?

ｒ No

ｒ Yes

b)Please list any medications (including dosage and frequency) that the applicant is currently taking as a result of prior or concurrent conditions identified in Part 9.

Were these medications prescribed by you?

ｒ No

ｒ Yes

Part 11

Health Practitioner

Signature

Name of Health Practitioner		College Registration Number

Facility Name (if applicable)		AISI Facility Number (if applicable)

Address

City		Province	Postal Code

Telephone Number	Extension	Fax Number

Email Address

You are a:

ｒChiropractor

ｒDentist

ｒNurse Practitioner

ｒOccupational Therapist

ｒOptometrist

ｒPhysician

ｒPhysiotherapist

ｒPsychologist

ｒSpeech-Language Pathologist

I confirm 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.

Name of Health Practitioner (please print)	Signature of Health Practitioner	Date (YYYYMMDD)

Note: The fee for completing this certificate is not a health care benefit of the Ontario Ministry of Health and Long-Term Care. This fee should be billed to the insurer directly.

OCF-3 (11/04)

Page 5 of 5

Question	Answer
Form Name	Ocf 3 Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	ocf disability certificate online, ocf 3 fee, ocf3 form, 3 disability fsco form

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