C988

PROSTHETIC AND ORTHOTIC SERVICES

P.O. BOX 2415
EDMONTON, AB T5J 2S5
Physician Assessment
FAX: 780-427-5863
1-800-661-1993
Microprocessor or Myoelectric Device
WCB Claim Number
WORKER DETAILS [Claim#]
Surname First Name and Initial Date of Birth (yyyy/mm/dd)
[Surname] [FirstName]
Provider’s Name and Title Provider’s Fax Number Provider’s Phone Number

Date of Service (yyyy/mm/dd) Provider’s Billing Number Service Code Provider’s Reference Number
RF06

Recommendations to achieve any criteria below, if not met

ASSESSMENT CRITERIA

Part of body: Side of body:

Type of device:

1. Worker is medically stable and will not need any revision surgeries. Met

Comments:

2. Current weight of worker and discuss whether workers weight has been relatively Met
stable these past 12 months.

Comments:

3. Worker is in a permanent socket and can tolerate wearing their current prosthesis Met
for a minimum of 5 hours a day/ 7 days a week.

Comments:

4. Do you support provision of a microprocessor/myoelectric device to this Yes No

worker at this time?

5. Additional Comments:

If you have any questions regarding the information or would like to discuss, please contact the
undersigned.

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
C – 998 REV AUG 2020 Page 1 of 2
P&O Physician Assessment
(Surname) (First Name) Claim Number
[Surname] [FirstName] [Claim#]

Provider's Name Billing Address Date (yyyy/mm/dd)

Title

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
C – 998 REV AUG 2020 Page 2 of 2