WCB Health Care Services - WCB Alberta



Service DescriptionNew Vehicle Modification Assessments are used to enhance the independence of severely injured Workers with regard to their ability to travel. These assessments aid in the identification of a new vehicle and the appropriate adaptations required by the Worker to either independently drive or be transported as a passenger. This information may be used to purchase a new vehicle and adaptations as required by the Worker’s needs.The service provider shall not render an opinion directly to the Worker with respect to the extent of their injury, compensation, treatment, vehicle or modification needs without prior WCB claim owner authorization. The service provider shall direct the Worker back to the attending claim owner to address these issues.Reporting/Service GuidelinesThe service provider will commence the assessment within five (5) working days from the date of referral.The service provider will provide the completed New Vehicle Modification Assessment Report to the WCB within five (5) working days from the date of assessment.The report will address the criteria as outlined in the New Vehicle Modification Assessment Guideline, as well as specific issues and questions identified by the Claim Owner, including rationales for recommended modifications where noted on the form.The report shall be typewritten.Report Field:WCB Claim NumberContent Expectations:This is the seven-digit number used by the WCB to identify a Worker’s claim for a specific condition (e.g. 439-8625).Report Field:Worker NamesContent Expectations:The full name of the Worker using the following specific format:Surname in mixed case (e.g. Canuck)First name and middle initial (if any) in mixed case (e.g. Joseph S)Report Field:Personal Health NumberContent Expectations:The Worker’s nine (9) digit health care number in the following format (e.g. 12345-6789)Report Field:Date of BirthContent Expectations:The Worker’s date of birth (yyyy/mm/dd format)Report Field:Referral DateContent Expectations:The date that the referral is received by the provider (yyyy/mm/dd format)Report Field:Assessment DateContent Expectations:The date of the assessment (yyyy/mm/dd format)Report Field:Date of AccidentContent Expectations:The date that the accident took place (yyyy/mm/dd format)Report Field:Provider’s Contact NameContent Expectations:The name of the provider who completed the assessment.Report Field:Telephone NumberContent Expectations:The provider’s ten (10) digit phone number (e.g. 403-725-4432)Report Field:Provider Reference NumberContent Expectations:The provider’s internal file numberReport Field:Compensable Conditions (based on referral form)Content Expectations:What is the work related injury accepted under this claim?Does the Worker have medical restrictions related to this claimReport Field:Non Compensable Conditions (based on referral form)Content Expectations:Are there conditions or injuries that are not accepted under this claim that will impact the Worker’s ability to perform home maintenance activities?Other WCB claimsOther conditions or diseases unrelated to a WCB claimReport Field:Employer’s NameContent Expectations:The name of the Worker’s date of accident employer (company name)Report Field:Employer’s Contact NameContent Expectations:The contact name of the Worker’s date of accident employerReport Field:Telephone NumberContent Expectations:The employer’s ten (10) digit phone number (e.g. 403-725-4432)Report Field:OccupationContent Expectations:The Worker’s date of accident occupationReport Field:NOC NumberContent Expectations:The four (4) digit National Occupation Classification numberReport Field:Job AttachedContent Expectations:Check the most appropriate box.Report Field:Assessment SummaryName of permanent compensable disability – check the most appropriate boxDescribe any functional abilities the Worker has related to driving (e.g. sitting balance, hand function, vision, and attention).Current transportation – check the most appropriate boxVehicle AdaptationsCurrent vehicle – check the most appropriate boxProvide the make, type, year and color of the Worker’s preferred vehicleCheck all equipment used in the Worker’s current vehicleCheck all equipment recommended for the Worker’s new modified vehicleIndicate if the adaptation(s) are medically necessary or as per the Worker’s choiceType of AdaptationCurrent VehicleRecommended for New VehicleMedically NecessaryWorker ChoiceAir conditioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX If yes, indicate where air conditioning is needed: FORMCHECKBOX Front FORMCHECKBOX BackHand controls FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Right hand signal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Raised roof FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Raised door FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lowered floors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Spinner knob FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Power adjustable seat FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Left foot gas FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Left foot controls FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Remote starter FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Power/Remote doors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Wheelchair lift FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX If yes, indicate type of wheelchair: FORMTEXT ?????Age: FORMTEXT ?????Running boards FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Handbrake FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Truck box canopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Privacy glass FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Generator/Battery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other (Specify): FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Provide information on the additional items listed regarding the vehicle (types of switches, windows, etc)Provide the name of who installed the above equipment and when it was installedProvide the date of the last vehicle modification (yyyy/mm/dd format)Has the Worker had an adapted driving assessment? (Yes/No)If yes, attached a copy of the assessmentProvide the name of the preferred dealer for vehicle modifications (if any)5.Specify any other customization needed and provide rationale.Where will the vehicle be parked at home and at work? – check the most appropriate boxAt HomeAt WorkOutside FORMCHECKBOX FORMCHECKBOX Inside (enclosed garage) FORMCHECKBOX FORMCHECKBOX If the vehicle is parked inside, provide the height clearance of the garage door at home and at workProvide the area available on the exiting side of the vehicle for the Worker to load/unload in a wheelchair at home and at workWhich side is it? – check the most appropriate boxWhat type of roads does the Worker normally travel? – check the most appropriate boxDoes the Worker have other vehicle needs (e.g. 4x4, pulling a trailer or boat)? (Yes/No)If yes, describe ................
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