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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)

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
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 #
TERMS OF SERVICE

  • 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
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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