Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)

Scale of Fees

Annual Increase in Medical Tariffs for Medical Service Providers - 2018

Physiotherapy Services, Occupational Therapy Services and Chiropractor Services

Occupational Therapy Services

Annexure B : Occupational Therapy request for wheelchairs and assistive devices
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ANNEXURE B

 

OCCUPATIONAL THERAPY REQUEST FOR WHEELCHAIRS AND ASSISTIVE DEVICES

 

Claim number

Name

Identity Number

Address


Postal Code:

Name of Employer

Address


Postal Code:

Date of accident

 

 

MOTIVATION

 

1.Diagnosis

 

2.Describe patient's current symptoms and functional status

 

 

 

3.Equipment currently being used

 

 

 

4.Equipment recommended

 

 

 

5.Motivation for equipment (with reference to home/work environment)

 

 

 

6.Quotes included (minimum of three)

 

 

 

Signature of rehabilitation service provider:                                                                        
Practice Number:                                                                        

Date: