Health care forms

 

Timely and complete reports help workers receive appropriate medical care when they need it. This is a legislative requirement and also a standard outlined in agreements with the New Brunswick Medical Society (NBMS), New Brunswick Chiropractors Association (NBCA) and New Brunswick Private Practitioners of Physiotherapy (NBPPP). Physician, nurse practitioner and chiropractor reports are due within 72 hours of the injured worker’s appointment. 

 

Forms

Physicians, nurse practitioners     

Medical Form 8-10
Doctor's Account for Consultations and Procedures
Surgery Billing Form for WorkSafeNB Claimants
Anaesthesia Billing Form for WorkSafeNB Claimants
Referral Service Form WRC

Chiropractors Chiropractor Form 8-10 
Audiologists

Form HA-01 – Hearing Aid Fitting and Service Report
Form HA-02 – Exception Report
Audiometric Report

Physiotherapists Physiotherapy Progress Report
Psychologists

Initial Psychology Assessment Report (PDF) 
Initial Psychology Assessment Report (Word) 
Psychology Progress Report (PDF)
Psychology Progress Report (Word)
Psychology Discharge Report (PDF)
Psychology Discharge Report (Word)

Dentists

Estimate of Required Dental Services

Social workers, counselling therapists

SUCCEED Discharge Report
SUCCEED Mental Health Questionnaire

Pharmacists

Form 33 – Claimant Prescription Information

WorkSafeNB adheres to the Right to Information and Protection of Privacy Act and the Personal Health Information Privacy and Access Act. Learn more about our privacy and confidentiality requirements.

How to submit reports:

  • MyServices (preferred): Register for MyServices to upload reports, check invoice status and email case managers securely.
  • Fax (toll-free): 1 888 629-4722
  • Mail: WorkSafeNB, 1 Portland St., P.O. Box 160, Saint John, N.B.  E2L 3X9

Please ensure forms are complete before submission. If you fax a form, do not mail it as well.

Physician inquiry line: 1 877 647-0777
Use this dedicated phone line for questions on medical forms and claims.

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