Ontario Claim Form 18 (OCF-18)
Treatment and Assessment Plan

Effective October 1, 2016.

Please provide information for the completion of Parts 1 and 2 and 3. After your
regulated health professional has reviewed your Treatment and Assessment Plan
with you, sign Part 10 and initial Part 12.

Your regulated health professional will complete all other parts of the form.

Remember that the collection, use and disclosure of this information are subject to all applicable privacy legislation.

Additional disclosure and consent may be required depending on the manner in which the information is used and disclosed.

As indicated on the form, all attachments are sent directly to the insurer.

All fields must be completed subject to the following exceptions:

• *required if known;
• **at least one field in this section; and
• ***optional

To the Regulated Health Professional/Facility:
To the extent possible, your regulated health professional/facility should ensure that this Treatment and Assessment Plan includes all goods and services contemplated by them, which is referred to in Part 5.

A health practitioner (i.e., chiropractor, dentist, nurse practitioner, occupational
therapist, optometrist, physician, physiotherapist, psychologist, speech language
pathologist) must sign Part 4.

Your regulated health professional/facility must complete Part 6 based on their most recent examination of you and return the form to your insurance company listed in Part 2.

Please print clearly.

Concerning consent, please remember that it is the responsibility of your regulated health professionals to ensure that their collection, use and disclosure of the information that you submitted to them are authorized by a consent form. For example, Ontario Claims Form 5 (OCF – 5) Permission to Disclose Health Information may be used as a consent form.

Please note that an OCF-18: Treatment and Assessment Plan form is not required to make the following claims:

• ambulance or other goods or services provided on an emergency basis not more than 5 business days after the accident;
• drugs prescribed by a regulated health professional;
• dental goods or services (submitted on the Standard Dental Claim Form);
• goods referenced in s.15(1)(d) to (f) and s.16(3)(h) to (j) with a cost of $250 or less per item; and
• goods and services referenced in s.15(1)(h) or 16(3)(l) if the insurer agrees the expense is essential for the treatment or rehabilit.

Also remember that if you only sustained an injury or an impairment that comes within the Minor Injury Guideline applicable to your motor vehicle accident (for accidents that occurred on or after September 1, 2010), then an OCF-23: Treatment Confirmation Form is required instead of this form.