Ontario Claim Form 19 (OCF-19)
Application for Determination of Catastrophic Impairment
Effective June 1, 2016.
This form must be completed in full and submitted to your auto insurer if you wish to establish that you have suffered a catastrophic impairment as a result of your motor vehicle accident.
If you are determined to have a catastrophic impairment, then you are entitled to request extended medical, rehabilitation and attendant care benefits and other expenses.
On the basis of this Application, your insurer may designate you as catastrophically impaired.
To the Physician*:
Concerning consent, please remember that it is the responsibility of the physician to ensure that their collection, use and disclosure of the information you submitted to him or her is authorized
by a consent form. The Ontario Claims Form 5 (OCF-5): Permission to Disclose Health Information may be used as a consent form, although additional disclosure and consent may be required depending on the manner in which the information is used and disclosed.
Lastly, if your accident-related impairment is a brain impairment only, then this form may be filled out by a neuropsychologist.
If you want to learn more about the companion accident benefits claim, and kickstarting the accident benefits application process, then please click the “link” to read my blog entitled “How to Get Your Accident Benefits Application Started”.
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