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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
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)

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
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 #
TERMS OF SERVICE

  • 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
SIGN & SUBMIT

Electronic Signature 

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

Patient/ Guardian nameyour full name
Dateof appointment
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