OCF-3

Disability Certificate
(OCF-3)
Return this form to
Use this form for accidents that occur on or after November 1, 1996.
Claim Number
Policy Number
Date of Accident

Month Day Year
Date
Use this form for accidents that occur on or after November 1, 1996. If your insurance company asks you to complete this form, fill out Parts 1 to 3 and give the form to your health practitioner (chiropractor, dentist, nurse practitioner, occupational therapist, optometrist, physician, physiotherapist, psychologist, speech language pathologist After your health practitioner has explained your accident-related injury to you, sign Part 4. Your health practitioner will complete the rest of the form, based on his/her most recent assessment, and return it to the insurance company.

Only an authorized health practitioner can complete this form. The health practitioner’s opinion will be relied upon by people who review the certificate to make important decisions. Accordingly, it is necessary to be accurate and complete. Please print clearly and provide all information requested. This form may not be materially altered.

Confidentiality: Collection, use and disclosure of this information is subject to all applicable privacy legislation.
Part 1 Applicant Information
To be completed by the applicant
Date Of Birth (YYYYMMDD)

Month Day Year
Date
Gender

Male Female
Telephone Number
Extension
Name

First Name Last Name
Middle Name
E-mail (optional)
example@example.com
Address
City
Province
Postal Code
Are you currently working?

Yes No
If No (to above question, when was the last date that you worked?
YYYY MM DD
Were you working at the time of the accident?

Yes No
If Yes (to question above), what type of work were you doing?
Did you work at least 26 weeks of the previous 52 weeks preceding the accident or were you receiving Employment Insurance during that time?

Yes No
Were you receiving Employment Insurance at the time of the accident?

Yes No
Were you the primary caregiver for anyone you lived with at the time of the accident? (see Part 6 for definition)

Yes No
Were you enrolled in an education program (elementary, secondary, post-secondary or continuing education) at the time of the accident?

Yes No
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Part 2 Insurance Company Information
To be completed by the applicant
Name of Insurance Company
City or Town of Branch Office (if applicable)
Name of Insurance Company Representative
E-mail (optional)
example@example.com
Telephone
Fax
Name of Policy Holder same as

Applicant OR
Name

Policy Holder First Name Policy Holder Last Name
Part 3 Accident Description
Give a brief description of the accident and what happened to you. Please describe any injuries you sustained as a direct result of the accident.
additional sheets attached
Part 4 Applicant Signature
I authorize my treating health professional to collect, use and disclose to my insurer or to a health professional, social worker, or rehabilitation expert properly identified by my insurer to conduct an examination, only such information relating to my health condition and treatment received as a result of the automobile accident and any pre-existing or subsequently occurring health conditions that may be barriers to my recovery as a result of the automobile accident, as is reasonably required for the purpose of providing treatment and determining my eligibility for benefits. I authorize the health practitioner who completes this form to contact my employer, if this is necessary, to confirm the essential tasks of my employment and the nature and extent of any available work with modified hours or duties.

This authorization does not apply to a consultation between my health care provider and the insurer’s health professional conducting an examination Separate express consent is required for this consultation. This consent should be in writing.

I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT.

I UNDERSTAND THAT IT IS AN OFFENCE UNDER THE INSURANCE ACT to knowingly make a false or misleading statement or representation to an insurer under a contract of insurance.

I FURTHER UNDERSTAND THAT IT IS AN OFFENCE UNDER THE FEDERAL CRIMINAL CODE for anyone, by deceit, falsehood, or other dishonest act, to defraud or attempt to defraud an insurance company. This information will be used for processing payments of claims; identifying and analysing the nature, effects and costs of goods and services that are provided to automobile accident victims, by health care providers; and PREVENTING, DETECTING AND SUPPRESSING FRAUD.
Name of Applicant or Substitute Decision Maker (please print)
Signature of Applicant or Substitute Decision Maker

Clear
Date (YYYYMMDD)

Month Day Year
Date
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To the Health Practitioner:

Please complete the following information based on your most recent examination of the applicant named in Part 1 and return the form to the insurance company listed in Part 2. Please print clearly.
Part 5 Injury and Sequelae Information

This part and the rest of this form must be completed by your Health Practitioner
Provide a description (list most significant first) and associated ICD-10-CA code for any injuries and sequelae that are the direct result of the automobile accident. (Refer to the User manual at www.hcaiinfo.ca for ICD-10-CA coding information
Description (1)
Code (1)
Description (2)
Code (2)
Description (3)
Code (3)
Description (4)
Code (4)
Description (5)
Code (5)
Part 6 Disability Tests and Information

To be completed by the health practitioner
Date symptoms first appeared:
YYYY MM DD
Date of most recent examination:
YYYY MM DD
Date of first post-accident examination:
YYYY MM DD
Is the applicant substantially unable to perform the essential tasks of his/her employment at the time of the accident as a result of and within 104 weeks of the accident?

Yes No N/A
Can the applicant return to work on modified hours and/or duties?

Yes No N/A
If yes, please explain
Does the applicant suffer a complete inability to carry on a normal life? (i.e., Has the applicant sustained an impairment that continuously prevents the person from engaging in substantially all of the activities in which the person ordinarily engaged before the accident?)

Yes No
If yes, please explain
As the Primary Caregiver, does the applicant suffer a substantial inability to engage in the caregiving activities in which he/she engaged at the time of the accident? (Primary Caregiver means that, at the time of the accident, the applicant was residing with a person in need of care and the applicant was the primary caregiver for the person in need of care and did not receive any remuneration for engaging in caregiver activities).

Yes No
Is the applicant, as a result of the accident, unable to continue in an elementary, secondary, post-secondary or continuing education program that the applicant was enrolled in at the time of the accident?

Yes No
Does the applicant suffer a substantial inability to perform the housekeeping and home maintenance services that he/she normally performed before the accident?

Yes No
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If you responded ‘Yes’ to any disability test above, what is the anticipated duration?

1-4 weeks 5-8 weeks 9-12 weeks more than 12 weeks
If you responded Anticipated Duration ‘more than 12 weeks’ to any disability test above, please explain why the task/activity limitations are likely to persist beyond 12 weeks. Please explain
Part 7 Further Investigations or Consultations
a) Have there been any examinations, investigations, or consultations not previously reported by you?

No Yes (please specify findings and results)
b) Are further examinations, investigations or consultations contemplated or required?

No Yes (please specify)
Part 8 Prior and Concurrent Conditions
a) Prior to the accident, did the applicant have any disease, condition or injury that affected his/her ability to perform the activities listed in Part 6?

No Unknown Yes (please explain below)
If yes, is the applicant currently receiving any disability benefits for the pre-existing disease, condition or injury?

No Unknown Yes (please explain below)
If you treated the applicant for similar conditions prior to the accident, please describe (include date of onset, any subsequent interventions, and status at the time of the accident).
b) Since the automobile accident, has the applicant developed any disease, condition or injury, not related to the accident, that could affect his/her disability?

No Unknown Yes (please explain below)
Effective (2016-06-01) © Queen's Printer for Ontario, 2016
Part 9 Medications
a) Please list any medications (including dosage and frequency) that the applicant is currently taking for injuries related to the automobile accident. Were these medications prescribed by you.

No Yes
List medications below
b) Please list any medications (including dosage and frequency) that the applicant is currently taking as a result of prior or concurrent conditions identified in Part 8. Were these medications prescribed by you?

No Yes
List medications below
Part 10 Health Practitioner Signature
Name of Health Practitioner
College Registration Number
Facility Name (if applicable)
AISI Facility Number (if applicable)
Address
City
Province
Postal Code
Telephone Number
Extension
Fax Number
Email Address
example@example.com
You are a:

Chiropractor Dentist Nurse Practitioner Occupational Therapist Optometrist Physician Physiotherapist Psychologist Speech-Language Pathologist
I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT.

I UNDERSTAND THAT IT IS AN OFFENCE UNDER THE INSURANCE ACT to knowingly make a false or misleading statement or representation to an insurer under a contract of insurance. Regulated sectors may be subject to an examination or inquiry about matters in connection with a licence and or unfair or deceptive act or practice. Non-compliance with applicable regulations may result in enforcement actions ranging from an administrative monetary penalty to prosecution under the Provincial Offences Act.

I FURTHER UNDERSTAND THAT IT IS AN OFFENCE UNDER THE FEDERAL CRIMINAL CODE for anyone, by deceit, falsehood, or other dishonest act, to defraud or attempt to defraud an insurance company. This information will be used for processing payments of claims; identifying and analysing the nature, effects and costs of goods and services that are provided to automobile accident victims, by health care providers; and PREVENTING, DETECTING AND SUPPRESSING FRAUD.
Name of Health Practitioner (please print)
Signature of Health Practitioner

Clear
Date (YYYYMMDD)

Month Day Year
Date
Note: The fee for completing this certificate is not a health care benefit of the Ontario Ministry of Health and LongTerm Care. This fee should be billed to the insurer directly.

Effective (2016-06-01) © Queen's Printer for Ontario, 2016
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Disability Certificate

(OCF-3)

Part 1 Applicant Information

Part 2 Insurance Company Information

Part 3 Accident Description

Part 4 Applicant Signature

Part 5 Injury and Sequelae Information

Part 6 Disability Tests and Information

Part 7 Further Investigations or Consultations

Part 8 Prior and Concurrent Conditions

Part 9 Medications

Part 10 Health Practitioner Signature