Ab-4 Form - Concluding Report (Accident Claims Benefit Package)
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Concluding Report
Form AB-4
Print
For accidents that occur on or after October 1, 2004
Send this form to the
To be completed by Claimant / Representative
appropriate insurer:
or a Primary Health Care Practitioner
Insurance Company
Policy Number
Fax #
Date of Accident:
(____)______-_________
(DD-MM-YYYY)
Part 1 – Claimant Information
Last Name
First Name
Date of Birth
(DD/MM/YYYY)
Date of Initial Assessment
(DD/MM/YYYY)
Part 2 – Information of Primary Health Care Practitioner
Name of Professional
Profession
Address
City, Town or County
Province
Postal Code
Scheduling Contact Name
Facility Name
Telephone Number
Fax Number
(Include area code)
(Include area code)
Part 3 – Assessment Status
Diagnosis at Initial Assessment:
Key Subjective and Physical Examination Findings at the last visit:
Functional Goals:
Progress towards goals
Regressed
1.
Improved Minimally
Improved Significantly
2.
Resolved
Plateaued
3.
Other (please describe)
Part 4 – Treatment Summary
Total Number of Treatments
Date of First Visit
Date of Last Visit
Total Cancelled/Missed Visits
(DD/MM/YYYY)
(DD/MM/YYYY)
AB-4 (2006/01)
Page 1 of 2
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