Ab-4 Form - Concluding Report (Accident Claims Benefit Package) Page 2

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Part 5 – Reason for Discharge or need for ongoing Treatment
Transferred to another treatment site
Other (please describe)
Full Recovery
Non-Attendance
Partial Recovery
Poor Compliance
Plateaued
No Contact
No Progress
Part 6 – Discharge Status
Is the claimant now working?
Are they employed or engaged in training activities?
Work or Training Restrictions?
Yes
Full Time
Retired
None
If Yes,
No
Part Time
Student
Yes
Temporary Restriction
Unknown
Seasonal
Not Employed
Permanent Restriction
Self-Employed
Has the claimant returned to a pre-accident level of activity outside work?
Did you refer the claimant to any other
If yes, who?
health care provider(s)?
Yes
Yes
No
No
Discharge comments (residual symptoms, signs, prognosis, details of exercise program, etc.):
Part 7 – Signature of Primary Health Care Practitioner
Name (Please Print)
__________________________________________________________
Signature _
Date
___________________________________________________________________
___________________________________
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AB-4 (2006/01)
Page 2 of 2

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