Sample - 2020 Service Provider Annual Information Return (AIR)

Step 1 of 7 - Introduction

Welcome to the 2020 Annual Information Return (AIR). The Financial Services Regulatory Authority of Ontario (FSRA) uses the information you provide in the AIR to help identify, assess and monitor risk in the service provider sector, and to calculate annual regulatory fees.

The deadline to file the AIR and pay the fee is June 30, 2021.

Don’t wait until the last minute! You can file anytime until June 30, 2021. At a minimum, please review Steps 1 and 2 as soon as possible, as you may be required to update information or have questions that may take several business days to respond.

The reporting period is January 1 to December 31, 2020. You must file the AIR even if you did not conduct any business during the reporting period.

Before you proceed

• Only the Principal Representative of the licensed service provider can attest to the information in the AIR.
• If the AIR is not filed and the fee is not paid by June 30, 2021, FSRA may immediately suspend or revoke your service provider licence. You may also be subject to an administrative monetary penalty. Any missed deadline will be noted on your file, which may increase the level of future enforcement action taken by the regulator.

Throughout this document, unless otherwise specified, “you” refers both to:

• the licensed business on whose behalf you are completing this AIR, and
• you as the Principal Representative.

What you need to file the AIR

Recommended computer requirements include:

• A secure, high speed internet connection via cable, DSL or wireless access
• The AIR is best viewed using Internet Explorer 11 (Windows) or Safari (OS X)
• Browser JavaScript (Enabled)
• Browser pop-ups (Enabled)
• Browser 128 Bit encryption (Enabled)
• Adobe Acrobat Reader

More information is available on FSRA’s website

Other Requirements

• Information from the previous calendar year (January 1 – December 31, 2020): Number of business locations and number of Statutory Accident Benefit Schedule (SABS) claimants.
• Note: These are required to calculate your annual regulatory fee. Valid forms of payment are as follows:
• For regulatory fees under $5,000, a valid VISA, MasterCard, or debit card must be used.
• Regulatory fees of $5,000 or more can only be paid by:
•  A certified cheque or money order payable to “FSRA”, or to the “Financial Services Regulatory Authority of Ontario” (mailed by June 15, 2021 in order to be received on or before June 30) or ;
• For the 2020 AIR only, electronic funds transfer may be available for regulatory fees. Please check FSRA’s website.

Please note: Consistent with FSRA’s role in promoting high standards of business conduct and protecting the rights and interests of consumers pursuant to s.3 (2) of the Financial Services Regulatory Authority of Ontario Act, 2016, FSRA collaborates with other organizations, including fraud prevention organizations and law enforcement agencies, to help combat fraud. Please be advised that the information you provide in this AIR may be shared with organizations that may collect and use this information, only as reasonably necessary, to enable them to carry out the purposes of detecting, suppressing and preventing fraud.

Ready to file the AIR?

The AIR will take you around 30-60 minutes to file. However, you can save your work at any time and come back to it later.

If you have finished reading Step 1, please confirm your agreement with the following to proceed to Step 2:

I, Principal Representative of the licence number indicated below, confirm that the information that will be provided in this Annual Information Return will be true to the best of my knowledge and belief.

Step 2 of 7 - Confirm license information

Please review the following information about your licence.

If any information has changed:

• Please click on the link to proceed to the supplementary change application.
• You will only be able to proceed with the AIR once you have been notified through the FSRA account that the change application has been processed.
• Licence number
• Licensed business (business legal name)
• Business ownership type
• Ontario mailing address for the business
• Principal Representative for the business
• Principal Representative email
• All Directors/Officers/Partners for the business
• Registered Trade Names for the business

Review completed – proceed

Step 3 of 7 – Confirm/edit licence information

Please identify whether the following information is correct or incorrect, or add new information if required.

• Principal Representative phone number
• Principal Representative fax number
• Principal Representative belongs to the following Regulatory Colleges (Regulated Health Professional governed by a College under the Regulated Health Professions Act, 1991 or the Ontario College of Social Workers and Social Service Workers under the Social Work and Social Service Work Act, 1998) as at December 31

Articles of Incorporation

Have there been any changes made to the business's Articles of Incorporation since the last time they were provided to FSRA/FSCO?

Please provide the CRA business number for the business: __________________________

Step 4 of 7 – Business information

4. Please review and update if necessary.

4.1 Franchise

Business has been granted a licence to do business under a franchisor’s trademark: Yes / No

Enter franchise name:

4.2 Business – Owners

Please indicate the total number of owners of the business, including any Directors or Officers who are also owners, as at the end of the reporting period (December 31, 2020):

At the end of the reporting period (December 31, 2020), were there owners who were not Directors or Officers of the business?

If there are more than 5, please list only the top 5 owners, based on the greatest percentage of ownership.

Owner name: Phone number: Regulatory College (if applicable):

4.3 Preferred provider

Was the business a participant of a Preferred Provider Network (PPN) and/or under contract for the purposes of Insurer-Initiated Exams on December 31, 2020? (y/n)

Please specify the purpose of the participation in the PPN and/or contract for the purposes of Insurer-Initiated Exams.

• Patient treatment including goods & supplies
• Both of the above
• Goods & supplies only
• Other

Please indicate with which insurers you had a PPN agreement and/or contract for the purposes of Insurer-Initiated Exams.

4.4 Total staff

At December 31, 2020, how many people in total worked for the business? _______

Include employees, contract, full-time, part-time, administrative and support staff, management, the principal representative, examination or assessment providers, care providers (whether regulated or not) and any others. Please provide the total for all staff including those who do not work on SABS business.

4.5 Motor vehicle accident claims business

During the reporting period, what percentage of the patients/clients served by the business were SABS claimants:

4.6 OCF submissions through HCAI

Provide the total number of people (including providers, administrative staff and others) who had access to enter invoices and/or treatment forms through HCAI on December 31, 2020:

4.7 Statutory declaration requests made under Statutory Accident Benefits Schedule 46.2 (1) 2

Insurers may request a statutory declaration from a provider as to the circumstances that gave rise to an invoice, including particulars of the goods and services provided. Service providers are required to give the insurer the information requested within 10 business days of the request.

During the reporting period (January 1 – December 31, 2020):

How many times did your business receive a section 46.2 request for a statutory declaration from an insurer in response to an invoice?

Note: Count each request received. For example, count as 2 if 2 requests are received for a single claimant or a single treatment plan.

Please list the top 3 insurers who requested a section 46.2 (1) 2 statutory declaration during the reporting period:

Insurer

1._____________________

2._____________________

3._____________________

List as many insurers as applicable.

Step 5 of 7 – Annual regulatory fee calculation

5.1. / 5.2. Annual regulatory fee calculation

Why is there a fee?

The Annual Regulatory Fee covers the yearly cost of regulating the service provider sector. The fee is due no later than June 30, 2021.

How is this calculated?

The Annual Regulatory Fee is calculated based on the data provided in the AIR for the prior calendar year (January 1 – December 31, 2020).

The Annual Regulatory Fee is calculated based on the following formula:

 A + B
"A" = $128 x the "Number of Locations" of the licensee.
"B" = $15 x the "Number of SABS claimants" of the licensee.

The answers to the following questions will be used to calculate your annual regulatory fee:

For the reporting period (January 1 to December 31, 2020), please indicate:

Number of locations ______

The number of physical locations at which the licensee operated the business that gave rise or could have given rise to listed expenses in the prior calendar year (January 1 to December 31, 2020) during the period in which the service provider held a licence from FSRA.

Note: Only locations registered with the Health Claims for Auto Insurance (HCAI) system count as business locations.

Number of SABS claimants ______

The total number of persons for which payment has been received for one or more listed expenses (calculated per accident) during the prior calendar year. A person may be counted more than once if they have been involved in multiple accidents.

Note: Neither FSRA nor Health Claims for Auto Insurance (HCAI) personnel has the ability to generate a list of your Statutory Accident Benefits Schedule (SABS) claimants; it is your responsibility.

For your reference: Health Claims Database* (HCDB) Number of Unique Claimants

FSRA uses information from the HCDB to supplement and validate information reported in the AIR. This includes a count of unique claimants for each service provider for the calendar year.

While the HCDB claimant count does not correspond precisely with the claimant count definition in FSRA’s Fee Rule, it offers a reference point that may assist you in validating the claimant count from your own records.

It remains your responsibility to ensure that the information provided in the AIR is complete and accurate.

Number of unique claimants** calculated by FSRA from HCDB for licence # SP99999: xxx

Comment: _____________________________________________________________

* The HCDB is maintained by HCAI Processing and contains depersonalized data gathered through the OCF forms used in processing SABS claims.

** Represents the number of unique claimants for whom the licensee submitted an OCF 21 B or C invoice during the 2020 calendar year, based on HCDB data as at December 31, 2021.

Step 6 of 7 – Compliance with regulatory requirements

6.1 Oversight obligation

6.2. Principal representative – system of supervision

Under s. #2(5) of Ontario Regulation 349/13 the principal representative is required to take reasonable steps to ensure that a system of supervision is in place to ensure compliance with the Insurance Act and to deal with any contravention of the Act.

Have you complied with this requirement: 

Periodic reviews Under s. #12(1) of Ontario Regulation 90/14, a licensed service provider is required to conduct periodic reviews of information submitted to insurers to ensure compliance with requirements under the Insurance Act and all applicable Guidelines. Have you complied with this requirement:

6.3 Policies and procedures

Section 17(1) of Ontario Regulation 90/14 requires service providers to establish and implement policies and procedures that are appropriate to the nature and volume of their business related to statutory accident benefits, and to meet the requirements set out in s. #17(2) and s. #17(3) of Ontario Regulation 90/14 .

Have you complied with this requirement:

6.4 Verifying patient identity

Section 5 of Ontario Regulation 90/14 requires the service provider to “take all reasonable steps” to verify the identity of each Statutory Accident Benefits Schedule (SABS) claimant.

Have you complied with this requirement:

Note: What constitutes all reasonable steps and due diligence is dependent on the unique set of facts specific to each case. The service provider should satisfy themselves as to identity, have a verification process that is reasonable for a given set of circumstances, and be able to demonstrate that the process is documented and was followed in any particular case, if and when required. For example, the service provider’s protocol could establish that if the service provider has verified a client’s identification at the initial visit, sees the same client on a regular basis, and recognizes him or her by sight, it may not be necessary to examine the person’s identification at each subsequent visit. However, it is up to the service provider to be able to prove that it was not necessary should an issue arise.

6.5 Claimant signature on OCF forms

Under s. #3(2)(7) of Ontario Regulation 7/00 it is an unfair or deceptive act or practice to require, request or permit a claimant to sign an OCF form before it is completed in full by the service provider. Please mark “yes” to confirm that you have not required, requested or permitted a claimant to sign an OCF form before it is completed in full by the service provider:

Note: Pursuant to section 65 of Ontario Regulation 34/10, if a substitute decision-maker is acting on behalf of a claimant, then reference to the claimant is deemed to include the claimant and their substitute decision-maker.

6.6 Virtual Care for SABS Claims

Have you provided virtual care for SABS claims during the COVID-19 Outbreak in the 2020 calendar year?

6.7 Receiving or paying a referral fee

Although referrals are not prohibited, under paragraphs 2, 3 and 4 of s. #3(2) of Ontario Regulation 7/00 it is an unfair or deceptive act or practice to solicit, receive or pay a referral fee in connection with statutory accident benefits claims. Please mark “yes” to confirm that you have not solicited, received or paid a referral fee in connection with any statutory accident benefits claims:

6.8 Security and integrity of records

Section 14 of Ontario Regulation 90/14 requires service providers to take all reasonable steps to ensure their paper and electronic records are secure and cannot be falsified. Have you complied with this requirement:

6.9 Rostered health professionals list in HCAI

Service providers are required to keep their rostered health professionals list up-to-date by adding an end-date to the rostered health professional’s record when they are no longer employed or working with the facility. The HCAI Enrolment section of Superintendent’s Guideline No. 02/18 outlines service providers’ responsibilities regarding the HCAI roster. Have you complied with this requirement:

Step 7 of 7 - Suitability

7.

FSRA continuously assesses the suitability of service providers to remain licensed in Ontario. Suitability requirements refer to businesses, as well as to their Principal Representative, and rostered health professionals. As the Principal Representative, you are required to provide information about yourself and about the business.

What offences must be disclosed?

Offences under federal statutes such as the Criminal Code, the Controlled Drugs and Substances Act and its predecessor the Narcotic Control Act, the Food and Drugs Act, the Income Tax Act (Canada), the Immigration and Refugee Protection Act (Canada), the Competition Act, and the Copyright Act are criminal offences and must be disclosed.

Charges and convictions under provincial statutes must also be disclosed. Such statutes include the Independent Health Facilities Act, the Regulated Health Professions Act, 1991, the Provincial Offences Act, the Insurance Act, the Mortgage Brokerages, Lenders and Administrators Act, 2006, the Registered Insurance Brokers Act, and the Human Rights Code, or their equivalent in other provinces.

If charges are pending or you have pleaded guilty or been found guilty of an offence under the above statutes, or any others, this information must be reported even if you were given an absolute or conditional discharge.

You do not have to disclose:

• any offence for which a record suspension (formerly known as a pardon) has been granted under the Criminal Records Act (Canada) and has not been revoked. Record suspensions are not automatically granted merely because of the passage of time. Nor is a record suspension automatically granted because you applied for one. Written confirmation from the National Parole Board of your granted record suspension is the only way to ensure a record suspension has been granted.
• convictions under either the Youth Criminal Justice Act or its predecessors, the Young Offenders Act or the Juvenile Delinquents Act.
• findings of guilt for traffic infractions such as speeding or parking violations.

If you answered "Yes" to any question in this section, please provide a full explanation in your own words in the window that will open. Please retain all relevant documentation for future reference.

7.1 7.2 7.3 7.4

Suspension, refusal or revocation of licence or registration
Principal Representative and business

• During the reporting period, did you or the business have a licence or a registration suspended or conditions imposed under any regulatory regime in Ontario or elsewhere? Y/N – please provide details
• During the reporting period, did you or the business have a licence or a registration refused under any regulatory regime in Ontario or elsewhere? Y/N – please provide details
• During the reporting period, did you or the business have a licence or a registration revoked under any regulatory regime in Ontario or elsewhere? Y/N – please provide details
• During the reporting period, were you or the business fined or were any monetary penalties imposed by any regulatory regime in Ontario or elsewhere excluding FSRA? Y/N – please provide details

7.5 Suspension, revocation or refusal of licence or registration

Rostered health professionals

• During the reporting period, did any individuals on your rostered health professionals list in HCAI have a licence or a registration suspended, revoked or refused, or have a fine or monetary penalty imposed under any regulatory regime in Ontario or elsewhere? Y/N – please provide details

7.6 Bankruptcy

Principal Representative and business

• During the reporting period, did you or the business declare bankruptcy, or make a voluntary assignment in bankruptcy; or are you or the business currently party to bankruptcy proceedings? Y/N – please provide details

7.7 Pleaded or found guilty of an offence or subject of charges

Principal Representative and business

• During the reporting period, did you or the business plead guilty or were you or the business found to be guilty of an offence under any law of any province, state or country; or are you or the business currently the subject of charges? Y/N – please provide details

7.8 Sued in a lawsuit

Principal Representative and business

• During the reporting period, were you or the business successfully sued in a lawsuit based, in whole or part, on fraud, theft, deceit, misrepresentation, forgery, or professional negligence? Y/N – please provide details

7.9 Complaints

Principal Representative and business

• During the reporting period, was a complaint made against you or the business to any regulatory body in a Canadian jurisdiction? Y/N – please provide details

Review and Attestation

Important: 

Before making the attestation and submitting the AIR please make sure that you have thoroughly reviewed all answers for accuracy. Once you have digitally signed the Attestation, no further changes can be made.

Providing false, misleading or incomplete information to FSRA in this AIR is an offence under the Insurance Act. Every individual convicted of an offence under this Act is liable to a fine of up to $250,000.

Additionally, providing false, misleading or incomplete information to FSRA in this AIR could form grounds for the Chief Executive Officer to suspend or revoke the service provider licence, or issue an administrative monetary penalty.