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APPENDIX 2
Note to Health Care Practitioner
Requesting Medical Note for Non-Payment of Medicine
< Date >
< Doctor's Name >
< Doctor's Address >
Dear Dr. < Surname >,
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Re:
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< Your Name >
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WSIB Claim No.:
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< Your Claim Number
>
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I am writing because I am concerned about the
Workplace Safety and Insurance Board's (WSIB) refusal to pay for
medication that you recently prescribed. Please find enclosed a
copy of the WSIB letter that describes the medication and the reasons
for refusal.
It is my understanding that you prescribed
this medication for my compensable medical condition. Could you
please prepare a note to the Adjudicator who refused payment that
includes:
- my name and claim number
- the reason you prescribed this medication
- the condition the medication is for
- how this medication would likely improve
my compensable medical condition.
If you did not prescribe this medication in
relation to my compensable medical condition, please contact me
directly and advise me as to the reason for the medication.
I recognize that this poses a demand on your
already busy schedule and that this note 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 note, please be advised
that WSIB has a fee schedule and may reimburse you. WSIB pays for
useful medical notes that assist in the decision-making process.
If you decide to bill me directly, please have your office contact
me before you start the note 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 note.
Yours truly,
< Sign Your Name Here >
< Type/Print Your Name >
< 123 Your Street >
< Your City, Ontario >
< X0X 0X0 >
Enclosure
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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
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OWA Workers' Kit 2 - March 2006
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