Functional Abilities Form - Wsib Page 2
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1
2
3
4Mail to:
or Fax to:
FAF
Functional Abilities Form
200 Front Street West
416 344-4684
for Planning Early
Toronto ON M5V 3J1
OR 1-888-313-7373
and Safe Return to Work
Claim No.
Please PRINT in black ink
Start >
A. Section A to be completed by the employer and/or worker.
First Name
Worker's Last Name
Telephone
Address (no., street, apt.)
City/Town
Province
Postal Code
Employer's Name
Date of Birth
(dd/mm/yyyy)
Full Address (No., Street, Apt.)
Date of Accident/
Awareness of Illness
(dd/mm/yyyy)
print
City/Town
Prov.
Postal Code
Employer
Telephone
reset
Employer
Fax No.
Area(s) of injury(ies)/illness(es)
1. Type of job at time of accident (where available, please attach description of job activities)
2. Have the worker and the employer discussed Return To Work
dd
mm
yyyy
lf no, will be discussed on
yes
no
3. Employer contact name
Position
B. Worker's Signature
By signing below, I am authorizing any health professional who treats me to provide me, my employer and the Workplace Safety and Insurance Board (WSIB) with
information about my functional abilities on the WSIB's "Functional Abilities for Planning Early and Safe Return to Work" form.
Signature
Date
dd
mm
yyyy
Please print form & sign before returning to the WSIB
C. Health Professional's Billing Information
For billing purposes fax or mail pages 2 and 3 to the WSIB.
Health Professional's Designation
Chiropractor
Physician
Physiotherapist
Registered Nurse (Extended Class)
Other
PROVIDER BILLING INFORMATION IN THE BOLDED AREA OF SECTION C SHOULD NOT BE PROVIDED TO THE WORKER OR EMPLOYER.
WSIB Provider ID.
Are you registered
yes
Please enter the WSIB Provider ID. in the box provided
with the WSIB?
no
Please call 1 - 800-569-7919 to register
Your Invoice Number
Health Professional's Name (please print)
Service Code
FAF
HST
Complete these fields if
is applicable to this form
Address (No. Street, Apt.)
HST Registration Number
Service Code
HST Amount Billed
ONHST $
.
Province
Postal Code
Fax
City/Town
I hereby declare that the information being submitted in Sections C, D, E and F of this form is true and complete. It is an
offense to knowingly make a false or misleading statement or representation to the WSIB.
Telephone
Date
Health Professional's Signature
dd
mm
yyyy
Please print form & sign before returning to the WSIB
page 2 of 4
2647A2 (07/06)
...go to next page
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