Wage Loss - Annual Medical Report

Please print this form and take it to your health care provider to complete.

This information is being collected for the purpose of administering and enforcing the Workers’ Safety and Compensation Act in compliance with the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the board’s privacy officer at 401 Strickland St., Whitehorse, YT, Y1A 5N8 or call 867-667-5645 or 1-800-661-0443.
In partnership with the worker, the board annually reviews wage loss claims. Your assessment of functional abilities regarding the worker’s workplace injury is important to assist the board with this review.
Please fax your separate invoice to the board at 1-867-667-8740. If you are a YMA member, please use code M0901 Progress Report for invoicing. All other health care providers can invoice for a wage loss progress report.

Service Provider Information

Worker Information

As shown on valid government-issued ID

Injury and Functional Information

Physical Workplace Injury

Psychological Workplace Injury

Signature, consent and declaration