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Auto Insurance Standard Invoice

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Auto Insurance Standard Invoice
Auto Insurance Standard Invoice
Auto Insurance Standard Invoice
Use this form for accidents that occur on or after November 1, 1996
**Claim Number:
**Policy Number:
Date of Accident:
To be used for medical and rehabilitation goods and services that are payable
by an automobile insurer. The User Manual for completion of the form and its
versions may be found at www.hcaiinfo.ca.
Confidentiality: Collection, use and disclosure of this information are subject to
all applicable privacy legislation.
As indicated on the form, all attachments are sent directly to the insurer.
All fields must be completed subject to the following exceptions:
*required if known
**at least one field in this section
Attach Version C - pages 2 and 3 for Minor Injury Guideline for accidents that occurred
on or after September 1, 2010 or Pre-Approved Framework (PAF) treatments for
accidents that occurred prior to September 1, 2010.
Attach Version A - page 2 where there is a previously approved treatment or
assessment plan.
Version B - pages 2 and 3 must be used for all other goods and services and may be
used for previously approved treatment plans and assessments, at the discretion of the
Part 1
Date Of Birth (YYYYMMDD) Gender
Male Female
*Telephone Number Extension
Last Name
First Name *** Middle Name
City Province Postal Code
Part 2
Company Name City or Town of Branch Office (if applicable)
*Adjuster Last Name *Adjuster First Name
*Adjuster Telephone Extension
*Adjuster Fax
**Name of Policy Holder same as:
Applicant OR
**Policy Holder Last Name *Policy Holder First Name
Part 3
Invoice Number First Invoice
Yes No
Last Invoice
Yes No
For previously approved goods and services, please complete the following:
*Type of Plan or Minor Injury Guideline or Pre-approved
Framework Treatments
*Plan Date
*Plan Number *Approved Amount *Previously Billed
Treatment and Assessment Plan (OCF-18)
Minor Injury
Guideline or PAF
Attach Version A or B For all other Invoices, attach Version B
Attach Version C
Part 4
Facility Name (if applicable) AISI Facility Number (if applicable)
Payee Last Name Payee First Name Payee Number (if applicable)
City Province Postal Code
Telephone Number Extension
*Fax Number
*Email Address
I certify that the information provided is true and correct. I understand that it is an offence under the Insurance Act to knowingly make a false or
misleading statement or representation to an insurer under a contract of insurance. I further understand that it is an offence under the federal Criminal
Code for anyone, by deceit, falsehood, or other dishonest act, to defraud or attempt to defraud an insurance company. This information will be used for
processing payments of claims; identifying and analysing the nature and costs of goods and services that are provided to automobile accident victims,
by health care providers; preventing fraud and detecting fraud where there are reasonable grounds to suspect fraud.
Name of Provider or Authorized Signatory (please print) Signature of Provider or Authorized Signatory Date (YYYYMMDD)
Effective date (2010/09/01)
FSCO 1208E
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Auto Insurance Standard Invoice