Contingency Fees Act, 1997
R 385.00
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
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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 |
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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:
