Dental Claim Form
Complete this form when seeking approval of dental claims.
Document
dentalclaim_2017_v3.pdf
(341.62 KB)
Hearing Loss Exception to Benefits Form
Complete this form when seeking approval of devices or services that are different from those outlined in the WCB Hearing Health Services Guide.
Document
Hearing Loss Exceptions Form Final.pdf
(87.85 KB)
Audiometric Report
Audiometric report to be completed by service provider.
Document
Audiometric Report.pdf
(302.32 KB)
Physician – Assistive Devices Request Form
Form to be completed by physicians for the request of an assistive device.
Document
Assistive_Devices_Form_Physician.pdf
(32.88 KB)
Service Provider – Assistive Devices Request Form
Form to be completed by service provider for request of assisted devices.
Document
Assistive_Devices_Form_ServiceProvider.pdf
(35.08 KB)
CTS - Physician Hand/Wrist Report
This form is required in order to assess the worker’s claim regarding hand/wrist symptoms being causally related to the workplace.
Document
Eye Injury Report
The form is required in order to assess the level of eye impairment, if any, with respect to the worker’s traumatic eye(s) injury(s).
Document
Eye Injury Report Aug2105 Final.pdf
(78.97 KB)
Primary and Emergency Care Report
This form is completed by physicians or nurse practitioners to report injury details, treatment, and return-to-work status for workers receiving primary or emergency care. Fax completed form to 902-491-8001.
Document
WCB-Primary-and-Emergency-Care-Report.pdf
(149.36 KB)