APPENDIX 4
Note to Chiropractor
Requesting Report for Non-Payment of Chiropractic Treatment

< Date >

< Doctor's Name >
< Doctor's Address >

Dear Dr. < Surname >,

I am writing because I am concerned about the Workplace Safety and Insurance Board's (WSIB) refusal to approve chiropractic treatment. 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 chiropractic treatment
• the condition the treatment is for
• how this treatment would likely improve my compensable medical condition
• how this treatment would teach me to independently manage my condition
• your physical findings and description of how chiropractic treatment has improved my level of functioning and reduced my pain or reliance on medication

If you did not prescribe this treatment for my compensable medical condition, please contact me directly and advise me as to the nature of and reason for the treatment.

I recognize that this poses a demand on your already busy schedule and that this report will take some 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

OWA Workers' Kit 2 - March 2006