C642

HOME HEALTH CARE SERVICES

P.O. BOX 2415 Assessment Report
EDMONTON, AB T5J 2S5
FAX: 780-427-5863
1-800-661-1993

Provider’s Reference Number WCB Claim Number

WORKER DETAILS [Claim#]
Surname First Name and Initial Date of Birth (yyyy/mm/dd)
[FirstName]
Address Street City/Town Province Postal Code Telephone Number

Assessment Date (yyyy/mm/dd) Date of Accident (yyyy/mm/dd)

Claim Owner’s Name Telephone Number

Initial Assessment Reassessment

Past Medical History:

Current Medical Status:

Medication Currently Prescribed

Type of Medication Dosage Frequency
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Assessment Findings:

Self Care Deficits:

Nursing Care Plan

Nursing Diagnosis:
Goal:
Expected Outcomes:

Comments:

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.

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Home Health Care Assessment Report
(Surname) (First Name) Claim Number
[FirstName] [Claim#]

RN Coordinator’s Name Telephone Number Date (yyyy/mm/dd)

Note to RN Coordinator
Fax this report to WCB with C727 Care Authorization Form

RN Coordinator’s Signature

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.

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