Authorization & Occupational Fitness Assessment (Ofa) Form printable pdf download

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Community Social Services Early Intervention Program (CSSEIP)

AUTHORIZATION & OCCUPATIONAL FITNESS ASSESSMENT (OFA) FORM

PURPOSE

This

confidential

form will assist the CSSEIP Medical Case Manager to:

•

confirm the anticipated duration of your sick leave

•

determine the type of work suitable to your medical restrictions

determine if other medical or rehabilitation processes would be beneficial

•

AUTHORIZATION

(

)

TO BE COMPLETED BY EMPLOYEE

I authorize any physician or practitioner, healthcare or rehabilitation provider, or any other person who has examined, diagnosed or

treated me (or who may do so), to release my personal information including full particulars of my medical history that are

reasonably necessary to process my claim to the Community Social Services Early Intervention Program (CSSEIP) and the

development of my return to work plan, to:

•

The Trustees of the Healthcare Benefit Trust and their agents (Trustees) which includes Great-West Life and the

Rehabilitation Services department at the Healthcare Benefit Trust; and

•

Designated representative(s) of the Union Bargaining Association; and

•

Designated representative(s) of the Community Social Services Employers’ Association.

I authorize the Trustees to give my personal information to other medical providers for necessary treatment.

I authorize my employer to provide the Trustees with information regarding my employment, my date of disability related to my

CSSEIP claim, and any other information reasonably necessary for the proper processing of my CSSEIP claim and the development

of my return to work plan.

I authorize the Trustees to disclose any information collected to process my CSSEIP claim, to Great-West Life for the purposes of

administering any Long Term Disability claim I may make.

I authorize the Trustees to use my Social Insurance Number as my identification number for this claim.

THIS AUTHORIZATION WILL REMAIN IN EFFECT FOR 6 MONTHS FROM THE DATE OF SIGNATURE

I confirm that a photocopy or electronic copy of this authorization shall be as valid as the original.

Print Name:

Signature of Claimant: ________________________________________

Date: _______________________________________

Telephone Number: _(_______)________________________________

Please include a copy of this page with physician’s statement

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Authorization & Occupational Fitness Assessment (Ofa) Form

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