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R 385
Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)Scale of FeesAnnual Increase in Medical Tariffs for Medical Service Providers - 2018Physiotherapy Services, Occupational Therapy Services and Chiropractor ServicesOccupational Therapy ServicesAnnexure B : Occupational Therapy request for wheelchairs and assistive devices |
ANNEXURE B
OCCUPATIONAL THERAPY REQUEST FOR WHEELCHAIRS AND ASSISTIVE DEVICES
Claim number |
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Name |
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Identity Number |
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Address |
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Postal Code: |
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Name of Employer |
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Address |
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Postal Code: |
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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: