CIRA MEDICAL SERVICES

Referral Form - Employer

EMPLOYER Information

Company
Street Address / Suite/Unit #
City / Province / Postal Code
First Name / Last Name
Phone# / Fax #
Email / Date of Injury

employee information

First Name / Last Name
Sex / Male / Female / Date of Birth
(mm/dd/yy)
Street Address / Suite/Apt#
City / Province / Postal Code
Phone / Email

requested assessments

Diagnostic Imaging
Bone Scan / CT Scan / MRI / X-ray / Other
Physical Assessments
Anesthesiology / Audiology / Cardiology / Chiropractic / Dentistry
Dermatology / Endocrinology / Gastroenterology / General Surgery / General Practitioner
Hematology / Infectious Disease / Internal Medicine / Immunology / Neuro-Opthamology
Neurology / Neurosurgery / Occupational Medicine / Orthopedic Surgery / Ophthalmology
Oral Surgery / Oncology / Otolaryngology (ENT) / Pediatrics / Physiotherapy
Plastic Surgery / Physiatry / Respirology / Rheumatology / Speech Language Pathology
Social Worker / Thoracic Surgery / Urology / Vascular Surgery / Other Specialty
Psychological / Psychiatric Assessments
Neuropsychology / Forensic Psychiatric Assessment / Psychiatry / Psychology
Occupational and Vocational Assessments
Job Site Analysis (JSA/PDA) / Functional Abilities Evaluation (FAE/FCE) / Ergonomic Assessment / Other
Vocational with Transferable Skills Analysis & Labour Market Survey / Vocational with Transferable Skills Analysis

additional services to be arranged by Cira

Transportation
Ground
Air / Yes / No / From / To
Translation
Required / Yes / No / Language:
Accommodation Required / Yes / No / Insturctions:
Please note that transportation and translation services will be arranged by Cira at no additional administrative cost. An invoice from the transportation and/or translation company will be sent directly to the referral source for payment.
Would you likeCira to initiate direct contact with theevaluee strictly to communicate the appointment details? / Yes / No / If so, how? / Phone / Letter / Both

NON-MEDICAL referral questions:

In your letter of instruction to the examining physician, you should include a brief history of occupational issues to date. Identifying dates of absence and reasons given, as well as any sick notes, is of paramount importance. This history can then be compared to the medical history in the GPs records.
You should also include a job demands analysis (or at the very least a job description) for the employee’s pre-absence position.
Finally, you should include any other relevant history you deem appropriate – conversations between the employee and you, the employee and others, behavioural observations by coworkers, etc.
In order to ensure your questions are answered, please indicate which questions you would like the assessor(s) to answer in their fitness to work report after the assessment has taken place.
Within the scope of your medical discipline, does the examinee have a bona fide medical condition precluding a return to work, full hours, full duties?
Within the scope of your medical discipline, what are the examinee’s current medical restrictions? Are these medical restrictions temporary or permanent in nature? If temporary, what is the anticipated length of the restriction?
Within the scope of your medical discipline, is the examinee able to resume work of any kind at this time? If not, when do you anticipate the examinee be capable of doing so?
If applicable, please detail the graduated return to work plan, including modified hours and/or duties.
Upon review of the proposed modified duties/hours (must be provided by employer), is the examinee capable of a return to work?
Within the scope of your medical discipline, is the examinee capable of modified duties at this time? If not, when will the examinee be able to do so? If applicable, please detail the graduated return to work plan.
Within the scope of your medical discipline, are the examinees reported symptoms and limitations supported by the existence of objective clinical evidence?
Within the scope of your medical discipline, please comment on the reasonableness of the examinee’s current treatment without disclosing medical information. Please also comment on whether the examinee has been compliant with treatment recommendations.
Within the scope of your medical discipline, are there any further recommendations you might suggest in order to enhance this individual’s return to maximum functioning?
Within the scope of your medical discipline, do you concur with the medical diagnosis/impairment/disability descriptions that have been provided to date by the treating practitioners?
Within the scope of your medical discipline, is further medical investigation required? If so, please detail in a separate letter to the family physician what investigations you recommend and why? If so, please advise us as to the approximate cost. (Pending approval from the employer, please arrange these investigations and provide a follow-up report)
Within the scope of your medical discipline, are there any work or non-occupational (social, family issues) impeding a more timely recovery?
Please indicate if there had been any non-medical barriers which have or are preventing a return to employment.
**Additional and/or alternative Questions can be typed on a separate document and attached to this referral form**

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