Ab-2 - Treatment Plan - Accident Claims Benefit Package

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Treatment Plan
Form AB-2
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 Accident
(DD/MM/YYYY)
Part 2 – Claimant’s Authorized Representative
Last Name
First Name
Middle Name(s)
Address
City, Town or County
Province
Postal Code
Relationship with Claimant
Parent
Guardian
Other
Telephone Number (Home)
Telephone Number (Work)
Fax Number
(Include area code)
(Include area code)
(Include area code)
Part 3 – Therapy Status Report
(To be completed by Primary Health Care Practitioner)
Diagnosis:
Key Subjective/Physical Examination Findings:
ICD-10-CA Injury Code*
Diagnosis
Sprain
1
2
3
Strain
1
2
3
WAD
1
2
3
4
Other
Is the claimant employed or engaged in training activities?
Full Time
Part Time
Seasonal
Self-employed
Retired
Student
Not employed
*ICD-10-CA injury codes are only required for Sprains, Strains and WAD injuries. It is recommended, not required, that ICD-10-CA injury codes be used
for other injuries when practical.
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AB-2 (2006/01)
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