Source: http://www.hcaiinfo.ca/Health-Care-Facility/Provider-Support/Form1.asp
Timestamp: 2017-09-25 06:02:02
Document Index: 652717677

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Health Care Facility - Provider Support - Form 1
Claim Identifier and Applicant Information
Auto Insurer Information
Attendant Care Assessment Information
Additional Comments & Submission
Create a form 1 template/draft
Download the Form 1 HCAI User Manual (PDF)
Form 1 Assessment Of Attendant Care Needs
The Form 1 is used to report the need for attendant care as the result of an automobile accident. It identifies the need for routine personal care, basic supervisory functions, and complex health/care and hygiene functions. The Form 1 must be completed by an Occupational Therapist or Registered Nurse who assesses the needs of the applicant.
There is currently no invoice for the Form 1 within the HCAI system. Invoices for attendant care services will continue to be submitted and processed outside of the HCAI system. For more information, please refer to FSCO’s bulletin about the Form 1 HCAI Pilot Project.
View Form 1 as PDF
This page will explain step-by-step how to complete each section of the Form 1. Use the side menu to jump to a specific section of the Form.
Form 1: Claim Identifier and Applicant Information
This section contains details about the claim, and information about the Patient. The Applicant (Patient) or Substitute Decision-maker should provide this information. (View screenshot)
Please note: Carefully entering Claim Identifier and Applicant Information is important for matching purposes. View Submitting and Storing forms for more information on matching.
You must enter either a claim number or a policy number. Only one of these numbers is required, not both. However, if you have both claim and policy number, it is helpful to insert both for matching purposes.
Enter the date of the accident using the calendar tool, formatted as shown
The following fields are mandatory: Date of birth, gender, first and last name, address, city, province, and postal code.
Form 1: Auto Insurer Information
This section includes the Patient’s automotive insurer details. The Applicant (Patient) or Substitute Decision-maker should provide this information. (View screenshot)
Select the insurance company to whom this form will be sent. Use the drop-down list and select from the available companies.
Please note: 100% of insurance companies are enrolled and using HCAI. Please be aware that independent adjusting firms will not appear in this drop-down list because they are not licensed insurers. To direct claim forms appropriately, HCFs should determine (typically by asking the patient or the Independent Adjuster) the name of the licensed Insurer that is managing the claim.
Indicate whether the policy holder is the same person as the Applicant (Patient).
If the Applicant is the person who holds the insurance policy, select “Yes”.
If the Applicant is not the policy holder, select “No”. For example, a child who has been injured in an accident would likely have coverage under his parents’ policy. In that case, enter the last name of the policy holder.
The last name of the policy holder is mandatory if the policy holder is not the same as the Applicant.
Form 1: Attendant Care Assessment Information
This section includes information about this assessment and any prior assessments. (View screenshot)
Select the date of the current assessment using the calendar tool.
If this was the Applicant’s first assessment, select the “Yes” radio button.
If there was a previous assessment, select “No”. An option will appear to enter the date of the last assessment. Use the calendar tool to enter the date.
Indicate if this Attendant Care Assessment is being conducted for the purpose of an Insurer Examination by selecting “Yes” or “No”.
Enter the Applicant’s current monthly allowance, if known.
Form 1: Signature of Assessor
This section contains information about the health care practitioner (referred to as the Assessor) who assessed the need for attendant care. (View screenshot)
Use the drop down menu to find the name of the health care practitioner (Assessor) who completed the assessment.
Select their profession.
Only Providers who are associated with your Facility, and who are occupational therapists or registered nurses, will appear on this list.
Indicate whether the signature of the Assessor is on file. The signature of the Assessor must be on file in order to submit the Form 1.
The Assessor who signs the Form 1 attests that the information in the form is accurate and that the assessor has obtained the appropriate consent from the applicant for the collection, use and disclosure of the information submitted.
In this section, the HCAI web application displays brief attestation wording. Full consent language is viewable on the paper or PDF versions of the Form 1 only. Once the Form 1 is complete, it must be printed, reviewed, and physically signed by the Health Practitioner and stored in the Applicant/Patient file at your facility. The Insurer or FSCO may request to see it.
Use the calendar to indicate when the form was signed.
Form 1: Part 1 - Level 1 Attendant Care
Part 1 is used to indicate the need for routine personal care. Here you will assess the care requirements of the Applicant for each activity listed. (View screenshot)
For each activity, estimate the number of minutes it takes to perform once.
Indicate the number of times each week that the activity needs to be performed.
If attendant care is not required for an activity that is listed, you may leave the corresponding boxes empty.
After filling out this section, click “Calculate”. HCAI will calculate the number of minutes per week for each activity, provide an Assessed Subtotal for each activity in Part 1, and calculate a Part 1 Assessed Total.
Form 1: Part 2 - Level 2 Attendant Care
Part 2 is used to indicate the need for basic supervisory functions. Here you will assess the care requirements of the Applicant for each activity listed. (View screenshot)
After filling out this section, click “Calculate”. HCAI will calculate the number of minutes per week for each activity, provide an Assessed Subtotal for each activity in Part 2, and calculate a Part 2 Assessed Total.
Form 1: Part 3 - Level 3 Attendant Care
Part 3 is used to indicate the need for complex health/care and hygiene functions. Here you will assess the care requirements of the Applicant for each activity listed. (View screenshot)
Next, indicate the number of times each week that the activity needs to be performed.
After filling out this section, click “Calculate”. HCAI will calculate the number of minutes per week for each activity, provide an Assessed Subtotal for each activity in Part 3, and calculate a Part 3 Assessed Total.
Form 1: Part 4 - Calculation of Attendant Care Costs
Part 4 is used to calculate the total monthly attendant care benefit based on the information you have provided in the previous parts of the Form 1.
Enter the Hourly Rate for Part 1, 2, and 3. The system will multiply the Hourly Rate by the Total Monthly Hours that were reported necessary for an attendant to care for the Applicant (Patient). (View screenshot)
Please refer to the hourly rates as set out in the Superintendent’s Guideline issued under s. 19 (2) (a) of the Statutory Accident Benefits Schedule (SABS). Download the most recent “Attendant Care Hourly Rate Guideline” from FSCO’s website. The total assessed monthly attendant care benefit is subject to the limits allowed under SABS.
Click ”Calculate”. You will see the Monthly Care Benefit for each Part, followed by the Total Assessed Monthly Attendant Care Benefit.
Form 1: Additional Comments & Submission
The Additional Comments section allows the facility to offer additional information about the Applicant, their injuries, care, treatment, response to treatment, or anything else that will help the Insurer understand the Applicant story.
You can cut and paste plain text—from a Word document, for example—but you cannot copy and paste complex tables, charts, or images.
There is a limit of 20,000 characters.
If you are sending attachments to the Insurer, check off the box next to “Attachments being sent, if any”.
If the box is checked, indicate the number of attachments being sent.
If the box is checked, you must use the space to describe the attachment(s). This tells the adjuster not to adjudicate the form until they have received the documents you are sending.
You cannot embed an attachment into the Form 1. Items like PDF files, Excel files, or Word documents must be faxed or mailed directly to the Insurer.
If you’d like to save the Form 1 as a draft, you can click “Save”. A yellow bar across the top will indicate that your form has been saved successfully. (View screenshot)
If you are ready to submit your Form 1, click “Submit”. The successful submission window will appear. (View screenshot)
A unique HCAI document number is generated. This number can be used to track this form. Insurance adjusters can also track this form in their system using this document number.
If you plan on filling out multiple Form 1s with similar information, you can save a draft Form 1 as a template that can be customized in the future. The save as draft feature is also useful if you need to stop in the middle of filling out a Form and resume at a later time.
To create a draft Form 1 from scratch:
Please note: If you are currently filling out a Form 1 but have not yet submitted it, you can use it to create your draft at any time. Skip to step 3 below.
To create a draft Form 1 from scratch, go to the Plans tab and the Work in Progress sub-tab.
Create a new Form 1 by selecting Form 1 from the drop-down list and clicking “Create new”.
In order to save the Form 1 as a draft, the following fields must be complete (but can be modified after saving):
Click on the “Save” button in the top right or bottom right of the Form window.
A yellow bar will appear on the Form stating “Document was saved successfully”. You can now exit the Form 1.
To use a draft Form 1:
You can access drafts that have been saved by clicking on the Draft sub-tab on the Plans or Invoices main tab. (View screenshot)
To open a draft, click on the magnifying glass button to the left of the OCF Type.
You may modify any fields as needed and then click “Save” again, or submit the form. Submitting the form will not delete the draft. The draft version will still be available in the Drafts sub-tab.
Click on the Drafts sub-tab of the Plans or Invoices main tab.
Select the checkbox to the left of the draft you wish to delete.
Click the “Delete” button at the bottom of the list.
Please note: It is best practice to delete any drafts that are older than one year. Drafts older than one year may reflect old versions of forms and may not be able to be submitted.
Download the Form 1 User Manual
This section contains de
Form 1 HCAI User Manual (PDF)