Form - MVA Claim Information & Authorization

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MVA Claim Information & Authorization

FORM #: 1026

PATIENT INFORMATION

Patient ID: _________________

Your Last NameYour Last Name

Your First NameYour First Name

Your Date of BirthYour date of birth

Gender

MaleFemale

Your Address (Street & number)Street and number

Your City

Postal Code

Home Phoneyour home phone

Work Phoneyour work phone

Cell Phonefor phone & text reminders

Physiomobility Health Group staff may leave phone messages at provided numbers for confirmation or changes to your scheduled appointments. (Please check the phone numbers below if you do not want us to leave phone messages)

Your Email Addressvalid email

By providing your email, you are consenting to email communication from Physiomobility Health Group such as appointment reminders, statements, invoices, exercise instructions, newsletters & commercial electronic messages.

Do not leave phone messages on these phone numbers:Chcek those that apply

Home PhoneWork PhoneCell Phone

ACCIDENT INFORMATION

Date of Accident (DD/MM/YY):

Date of Accident

PRIVATE INSURANCE INFORMATION

The laws in Ontario require that all invoices related to your treatments for injuries sustained in a Motor Vehicle Accident be submitted to your private/employer health insurance provider if available.

PRIMARY INSURANCE INFORMATION

Insurance Company Name

Policy/Group #

ID/Certificate #

Policy holder's name

Policy holders Date of Birth (DD/MM/YY)

SECONDARY INSURANCE INFORMATION

Insurance Company Name

Policy/Group #

ID/Certificate #

Policy holder's name

Policy holders Date of Birth (DD/MM/YY)

AUTO INSURANCE INFORMATION

Insurance Company Name

Policy #

Claim #

Phone Number

Insurance Company Address

Policy holder's name

Policy holders Date of Birth (DD/MM/YY)

Adjuster

Phone Number

Fax Number

LEGAL REPRESENTATIVE

Legal Representative Company Name

Legal Representative`s Name

Legal Representative`s Address

Postal Code

City

Phone #

Fax #

I hereby authorize Physiomobility Health Group to collect and release medical records, copies of treatment plans and financial and any other information related to my claim to above mentioned legal representative and third party payers (Private Insurance payer & Car Insurance).

I understand that I am legally responsible for providing Physiomobility Health Group with all information for my claim including any updates.

I direct all third party payers to pay Physiomobility directly for fees related to services provided for my injuries to this claim.
In the event of any settlement or agreement with insurance company, I will ensure all the unpaid services at Physiomobility Health Group for my injuries are paid in full including any interest. I understand that I will remain responsible for any unpaid balance.

Please check the below box if you agree to our terms of service above

I have read and agree to the Terms of Service above.

SIGN & SUBMIT

Electronic Signature

Please write Patient/Guardian full name below which serves as electronic signature.

Patient/ Guardian nameyour full name

Dateof appointment