THE DOMINION S QUALITY TREATMENT NETWORK DOCUMENTS

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THE DOMINION’S

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THE DOMINION OF CANADA GENERAL INSURANCE COMPANY

QUALITY TREATMENT NETWORK DOCUMENTS

Disclosure and Consent ... 1 Waiver of Submission (OCF 23) ... 3 The Dominion Quality Treatment Protocol ... 4

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The Dominion of Canada General Insurance Company Ι Compagnie d’assurance générale Dominion du Canada

Head Office Ι Siège Social: 165 University Avenue, Toronto, ON M5H 3B9 P. 416.362.7231 Ι 1.800.268.8447 F. 416.362.9918

Disclosure and Consent Form

As a valued client of The Dominion of Canada General Insurance Company, the company has developed a program that allows you priority access to a network of quality accredited rehabilitation facilities to assist you in promptly accessing the treatment or care that you may require as a result of injuries sustained in an accident as outlined in the Minor Injury Guideline and Statutory Accident Benefits Schedule (SABS). Active Health Management has identified itself to the Dominion as providing a high quality standard of care.

This is a pre-approved treatment plan. It will provide active rehabilitation therapy to you focused on effective management of symptoms, early return to activity, and the prevention of ongoing symptoms. While The Dominion will pre-approve your treatment in accordance with the program, you must first exhaust any extended health benefits that may be available to you such as through a private insurance plan or insurance plan through your employer.

This program will be pre-approved up to a maximum of $3500.00 in accordance with the monetary limits for minor injuries as set out in the SABS. The duration of treatment may vary, but may last up to 12 weeks in that regard. However, The Dominion will not pre-approve treatment if an insured person’s injuries fall outside of this limit and further treatment is subject to the limits as prescribed by the SABS. In that event, an insured person’s health practitioner must determine and provide compelling evidence that the insured person has a pre-existing medical condition that will prevent the insured person from achieving maximum medical recovery from their minor injury.

There are many advantages to participating in this program:

1. There is a wide variation of care marketed to people involved and injured in auto accidents. The facilities above have been identified as providing a good quality of care with good results and which have been accredited and evaluated.

2. The facilities will schedule an initial assessment within 24-48 hours to reduce any wait times.

3. You do not require a doctor’s referral to participate in the program, but reports may still be sent to your doctor to keep them informed of your progress.

4. These rehabilitation facilities have numerous clinic locations within Ontario that are conveniently located to provide you with services close to your home, school, or work.

5. There is less paperwork for you to complete if you participate in the program as the clinics have staff that can facilitate the completion of the necessary forms that must be submitted to The Dominion. 6. There is no cost to you associated with participation in the clinics’ services. The Dominion will

pre-approve the cost of treatment as noted above.

The Dominion of Canada General Insurance Company has no financial interest in these rehabilitation companies. They are paid in accordance with the Professional Fee Guidelines as published by the Financial Services Commission of Ontario, the government body that is responsible for regulating auto insurance in Ontario. The clinics are paid at the same rate that The Dominion pays any other rehabilitation provider in Ontario. The Dominion receives no preferential pricing, bulk discounts, or referral fees in relation to these programs.

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Please note that your participation in this program is completely voluntary. If you choose not to participate in this program, your entitlement to accident benefits will not be prejudiced or affected. You may withdraw from the program at any time without penalty, and your entitlement to accident benefits will not be prejudiced or affected. As well, you have the right to choose to receive services from another service provider.

I have read and understand the above information. I agree to participate in this program. I understand that if I decide to withdraw or choose my own service provider, my present and future entitlement to accident benefits will not be adversely affected.

_________________________ _______________________ ___________________ Participant’s Name Signature Date and time

_________________________ ________________________ ___________________ Witness’ Name Signature Date and time

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Waiver of Submission of OCF-23 Treatment Confirmation Form

We want to make it easier for you to get treatment quickly.

Government regulations (Statutory Accident Benefits Schedule, Accidents on or After September 1, 2010) say that a person who sustains a minor injury and wishes to receive treatment for those injuries must submit an OCF-23 Treatment Confirmation Form that meets the requirements of the legislation. Specific timing requirements are imposed.

However, with your participation in the Preferred Provider Network Program, The Dominion will waive the requirement of the submission of all Treatment Confirmation Forms (OCF-23 forms) while you are engaged in treatment with the Preferred Provider Network.

This Waiver is only valid while you are obtaining treatment from a facility in this program. Should you choose to receive services elsewhere from another service provider or should you withdraw from treatment or care with the Preferred Provider Program, this waiver does not apply and you should submit the prescribed forms. [The forms are in the package of documentation provided to you.] or [If you need a form, let us know.]

_________________________ _______________________ ___________________ Participant’s Name Signature Date and time

_________________________ ________________________ ___________________ Witness’ Name Signature Date and time

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The Dominion of Canada Protocol

MIG MMIG MIG Extension Non-MIG

Criteria

All minor injuries as defined by the Minor Injury Guideline (SABS).

Completed MIG and req’s further treatment.

Clinic Manager must review file and receive approval from Dominion Injuries are outside the MIG guideline (i.e. fractures, WAD 3, etc.)

Pre-existing medical condition excludes from the MIG.

Multiple barriers to recovery. Treatment

Length 12 weeks Another 4-8 weeks beyond MIG As per approval Treatment Cost Initial Assess. $215 Blocks 1, 2, 3 $1500 OCF-24 $85 Supp. G&S $400 Total = $2200.00 Up to a maximum of $3500.00 which includes the insured’s expenses

Completion of OCF 18 is required to be completed

Forms & Reports

 Waive OCF-23  Initial Assessment &

Discharge reports  OCF 24 if discharged  Program Transfer Report

(if req’d).

 OCF-21 (at end of each block)

 Waive OCF 18.

 Extension/interim report to be faxed to adj, Discharge report with OCF 24.

 OCF-21

 Assessment + OCF-18 ($200)  Disclosure Form (fax to Dominion)  Initial Assessment, Interim and

Discharge reports.  OCF-21

Massage Funding

1. Use EHB coverage first 2. May use Supplementary Goods and Services (Total of $400)

1. Use EHB coverage first. 2. Include on Extension Request 3. FSCO hourly rate

1. Use EHB coverage first 2. FSCO hourly rate

OT Funding

OT Screen (use one appt in Block 1)

Services are funded in the Supplementary Goods and

Include on Extension Request FSCO hourly rate

OT Screen ideally within 5 days post-mva

No services pre-approved, call adjuster for approval

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#1 then contact adjuster to clarify options (i.e. redirect from MIG to another treatment stream)

adjuster to clarify options. adjuster to clarify options

*For all treatment streams, if treatment not progressing as expected, clinic will notify adjuster within 3 weeks of onset of treatment. Disclosure form must be completed with time-stamp and faxed to Dominion Adjuster prior to treatment commencing