< ><<File No>><<Claim No>>

Insurance / Legal

Delivered by courier

<

<

<<CITY/PROV>>

< >

Dear <

RE: < > < >

DOB:< >

DOL: < >

CE Date/Time:< > @ < >

Report Due:<<report due date>>

Thank you for agreeing to examine this person as noted above, for the purposes of a <<Certified Examination.>>

Please note there is a tight deadline of <<deadline DATE>> for this report.

No medical documentation has been made available for your review.

***OR***

We enclose all documentation that has been made available to us.

According to the Minor Injury Regulations, the following information is required to be included in your opinion as a Certified Examiner. Please create a separate heading for each of the following in your report (especially for Items 5 through to 15):

Name and address of claimant.

Name and address of insurance company.

Date of assessment.

Name of parties requesting the opinion.

Date of Motor Vehicle Accident related to the injury.

Statement of the Purpose for the Examination and relevant issues, including a statement that the claimant’s consent was obtained for the examination to access relevant medical information and other records, and to disclose the results of the examination to the insurance company and claimant/claimant’s representative.

List of Information Reviewed including information from the primary healthcare practitioner(s), Regional Health Authorities, informed parties and, if applicable, the injury management consultant or other specialists.

Claimant’s Complaints including:

physical; and,

psychological.

History of Injury including:

working diagnosis;

mechanism of injury;

treatment to date and response to the treatment;

current symptoms; and,

how physical and cognitive functions have been affected by the injury.

Medical History including: physical, psychological, emotional and social history.

Employment History: relevant occupational/employment history.

Activities of Daily Living (home, recreation). Normal activities of daily living: basic, functional and current status.

Examination (details including):

general examination as appropriate;

regional examination as appropriate;

musculoskeletal and neurological examination as appropriate;

cognitive examination as appropriate; and,

functional limitations as appropriate.

Reference to the Minor Injury Regulation.

Conclusions and Determinations including but not limited to:

are the injuries sustained a sprain, strain or WAD injury as defined in the Minor Injury Regulation?

If a WAD, please indicate the grade.

If there are strain or sprain injuries, please confirm or deny that they are “minor”.

If there are injuries that do not fall under the definition of “minor” as defined in the Minor Injury Regulations, please describe these injuries.

Has any injury resulted in a current serious impairment?

Whether the claimant was treated within the Diagnostic and Treatment Protocols.

Name and address of the Certified Examiner.

Signature of the Certified Examiner and date of signature.

Please respond in a question and answer format.

Kindly address your report to:

< >< >

< >< >

< ><

< >< >< >< >

< >< >

Please quote our client’s claim number as noted above.

Please ensure your invoice is made out to Western Medical Assessments and not to our client.

Thank you for providing your services in this matter. We look forward to receipt of your report.

Yours sincerely,

WESTERN MEDICAL ASSESSMENTS CORPORATION

Roger Hodkinson M.A., M.B. (Cantab), FRCPC

Medical Director

RGH/sz

Encls.