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APPENDIX 1
Note to Heath Care Practitioner
Requesting Medical Report for Non-Payment of Treatment
< Date >
< Doctor's Name >
< Doctor's Address >
Dear Dr. < Surname >,
| Re: |
< Your Name
> |
| WSIB Claim No.: |
< Your Claim Number
> |
I am writing because I am concerned about the
Workplace Safety and Insurance Board's (WSIB) refusal to pay for
a medical treatment that you recently prescribed. Please find enclosed
a copy of the WSIB letter that describes the treatment and the reasons
for refusal.
It is my understanding that you prescribed
this treatment for my compensable medical condition. Could you please
prepare a report to WSIB that includes:
- my name and claim number
- the reason you prescribed this treatment
- the condition the treatment is for
- how this treatment would likely improve
my compensable medical condition.
If you did not prescribe this treatment for
my compensable medical condition, please contact me directly and
advise me as to the nature of the treatment.
I recognize that this poses a demand on your
already busy schedule and that this report will take time to prepare,
but I would not ask this of you if it were not important to me.
If you propose to charge a fee for your report, please be advised
that WSIB has a fee schedule and may reimburse you. WSIB pays for
useful medical reports that assist in the decision-making process.
If you decide to bill me directly, please have your office contact
me before you start the report so that we may discuss this matter.
I thank you in advance for your assistance
and attention to this and look forward to receiving your report.
Yours truly,
< Sign Your Name Here >
< Type/Print Your Name >
< 123 Your Street >
< Your City, Ontario >
< X0X 0X0 >
Enclosure
|
IMPORTANT INFORMATION
There are time limits for appealing WSIB decisions. If you
wish to appeal a decision, contact a qualified representative
as soon as possible. For more information on time limits,
see OWA Fact Sheets 24 and 25 called Appealing
to WSIB and Appealing
to WSIAT.
This Workers' Kit contains general information only. It
is not a legal document. To see what the law says, you should
look at the Workplace
Safety and Insurance Act and WSIB policies. If you
require help and do not have a union to assist you, contact
the Office of the Worker Adviser:
- Our toll free telephone
number is 1-800-435-8980 (English) or 1-800-661-6365 (French)
- or visit our website at http://www.owa.gov.on.ca
Cette Trousse du travailleur
est aussi disponible en français
|
OWA Workers'
Kit 2 - March 2006
|
