Forms - WSIB Claim Information & Authorization

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WSIB Claim Information & Authorization

FORM #: 1028

PATIENT INFORMATION

Patient ID: _________________

Your Last NameYour Last Name

Your First NameYour First Name

Your Date of BirthYour date of birth

Date of Accident

Claim NumberYour First Name

Employer NameYour First Name

Employer Address (Street & number)Street and number

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

Claim Number

Employer Name

Employer Address (Street and Number)

City

Postal Code

WORK INFORMATION

Supervisor/Contact name

Supervisor/Contact Phone

Patient’s current job title

Length of time in current job (YY/MM):

ADJUDICATOR INFORMATION

Adjudicator Name

Adjudicator Phone

Adjudicator Fax

CASE NURSE MANAGER INFORMATION

Case Nurse Manager Name

Case Nurse Manager Phone

Case Nurse Manager Fax

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 and other information related to my claim to the above mentioned legal representative, my medical doctor and WSIB.

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

WSIB will pay a standard fee for medical services related to your approved claim & requires a minimum number of treatment sessions based on applicable program of care. In the event of denial of your claim or non-compliance with the treatment plan causing your claim to disqualify, WSIB will contact you not the clinic. It will be your responsibility to inform Physiomobility of such decision. I understand that I am responsible for all unpaid fees.
I direct all third party payers including WSIB to pay Physiomobility directly for fees related to services provided for my injuries related to this claim.

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