Chiropractic Form 8-10

WorkSafeNB has streamlined reporting for chiropractors by combining the Form 8C, Chiropractor’s First Report of Accident and the Form 10C Chiropractor’s Progress Report into one form. The Chiropractic Form 8-10 is for both initial visits and follow-up (progress) reports. The new form encourages practitioners to consider functional abilities of an injured worker as an alternative to placing them off work. Physician’s reporting forms have undergone a similar process. Below is an explanation of the key changes and guidelines for form completion.

Patient:

At the top of the form please indicate if it is the first visit or a subsequent progress report. The Patient section is filled out in the usual manner. Please note the revised gender options.

Clinical Report:

The Clinical Report section has many tick boxes to streamline the process. Concussion/mTBI has been added as it is not uncommon for it to be part of an injury profile. Further details in this section are as follows:

• The Description of injury/illness only needs to be completed in the First Report.
• The symptoms and examination findings are required on all reports.
• An area is provided for x-ray findings.
• Tick boxes are provided to grade objective and subjective progress if it is a progress report.
• Any complicating factors affecting treatment, workplace, recovery etc., can be included and described in the designated area.
• Your best working diagnosis goes in the space indicated and can be changed should further information arise.
• Any further treatment recommendations can be indicated in the area provided.
• The treatment section should include treatment type, frequency of visits, how long before next re-evaluation and treatment goals.

Employer Note:

The information in the Employer Note section will be provided to the patient who will give it to their employer. Please consider modified duties as an alternative to being off work. Completion guidelines are as follows:

• Please indicate if the patient is able to return to perform their usual work duties by ticking box 1.
• If modifications to normal work duties are required, tick box 2 and indicate the functions the patient is able/unable to perform.
• Please tick box 3 if you would like to speak with WorkSafeNB about your case.
• Please indicate how many days your orders will be in effect.
• Any other limitations, modifications or comments can be written in the space provided including time off work if necessary.

Provider Section:

If you don’t have a payee number, please contact WorkSafeNB at 1 800 999-9775. Billing is according to the fee schedule available on the NBCA website as well as in the NBCA-WorkSafeNB agreement. The latter also serves as an operational guideline for the management of WorkSafeNB cases.

Page 2: Patient/ Employer Copy:

Please provide page 2 to your patient. Both pages can be completed by hand or digitally through fillable PDF. Page 2 will automatically populate with the required information if page 1 is completed digitally (fillable PDF).

For ease in filing your reports, use your secure MyServices account. If you have any questions on MyServices registration or Chiropractic Form 8-10, please call 1 800 999-9775.