General Intake Form

Motor Vehicle Accident Injuries
Are your injuries the result of a motor vehicle accident? *

Yes No
Date of Accident

Month Day Year Date Picker Icon
Policy Number:
Claim Number:
Insurance Company:
Address of Insurance Company:
Name of Policy Holder:
Date of Birth of Policy Holder (if not client):

Month Day Year
Date
Name of Adjuster:
Address:
Phone Number:

Area Code Phone Number
Fax Number:

Area Code Phone Number
Case Manager:
Extended Health Insurance?

Yes No
If yes, name of company:
Group Policy / Plan #:

Fees and Billing
This clinic is not covered by OHIP. You are responsible for any charges incurred at this clinic. The fee schedule is available at reception. Payment must be made directly to NeuroLogic Physiotherapy at each visit. Payments can be made by cash, cheque, debit card, Visa or MasterCard. Most extended health plans now cover physiotherapy treatment. You do not require a doctor's referral to attend physiotherapy; however, your insurance company may require one to process your claim. If you have any specific questions about our rates or your physiotherapy coverage, please do not hesitate to ask us.

NeuroLogic Physiotherapy Cancellation and No Show Policy

A significant amount of time is set aside for your appointment, and without prior notice the appointment slot cannot be filled. Thus, a 24-hour notice is required to cancel your appointment. After hours, a message may be left on our answering machine. Patients who do not give 24 hour notice and do not have a legitimate excuse (i.e. illness or inclement weather, etc.) will be charged the treatment fee. This charge is not covered by insurance companies. It will be the responsibility of the patient to pay this charge.

If You Are Hurt In a Motor Vehicle Accident (MVA)
If you have injuries stemming from a motor vehicle accident you must first complete and submit an OCF 1 form to your adjuster. It is recommended that you begin physiotherapy as soon as possible after your injury in order to allow for a quicker recovery from the time of the accident. Upon assessment of your condition, a physiotherapist will complete an initial report outlining his/her clinical findings along with a treatment plan indicating types and length of treatment recommended. These documents will then be sent to your insurance adjuster for review before authorization of the entire treatment plan is given.

Billing for MVA Insurance Claims Upon Approval of a Treatment Plan
- Billing for MVA Not-Catastrophic and Minor Injury Guidelines (MIG) Insurance Claims Upon Approval of a Treatment Plan
  
  - Our new clinic policy is you pay us upfront and submit for reimbursement from your EHI and MVA insurer. Our clinic rate for physiotherapy treatments are $130/session (1hr). As the FSCO rate is $99.75, there is a rate difference discrepancy that will not be reimbursed by your MVA insurer. You may pursue treatment elsewhere and not be required to pay upfront nor pay this discrepancy of rate difference.
  
  Billing for MVA Catastrophic Insurance Claims Upon Approval of a Treatment Plan
  
  -If you have available extended health insurance, it is our clinic’s policy that you pay upfront for all assessment and treatment costs at our clinic rates. To be reimbursed, you will first submit your paid invoice to your available EHI provider(s). If there is a portion that your EHI does not cover you would then provide us the EHI statement(s) showing what your EHI paid so that we can fax that proof to your MVA adjuster. We require these statements within 30 days following the treatment services (within 60 days if you are billed monthly due to in-home treatment service) so that we can bill your MVA insurer. Once we receive this reimbursement it will be extended to you in form of cheque. If and when you can provide paper proof that all available EHI is exhausted (we are required to fax this proof to your MVA adjuster) our clinic will direct payment towards your MVA insurer.
- **Please ask reception to review our Fee Schedule which outlines the rate difference between our clinic rates and the MVA maximum hourly rates approved.
I have read and acknowledged this policy *

Yes

Privacy Policy

The NeuroLogic Privacy Policy is available at the front desk or at this link. This provides a more detailed description of the use of this information. Please ask the receptionist for a copy.

I understand that to provide me with physiotherapy services, NeuroLogic will collect personal and health information about me. It is used primarily to deliver safe and efficient care, to communicate on your behalf with other health care providers and complete and submit claim forms for insurance adjudication and payment.

I understand how the Privacy Policy applies to me. I have been given a chance to ask any questions I have about the Privacy Policy and they have been answered to my satisfaction.

I agree to NeuroLogic Physiotherapy collecting, using and disclosing personal information about me as set out above and in the NeuroLogic Privacy Policy. I am aware that I have access to this information and that I can withdraw this consent at any time.

I understand that NeuroLogic Physiotherapy is considered the Health Information custodian and not my individual therapist.
Name *

First Name Last Name
Signature *
Date *

Month Day Year
Date
Consent for Physiotherapy Assessment

I consent to a comprehensive physiotherapy assessment, which may consist of manual techniques, therapeutic exercises, electrotherapeutic modalities, acupuncture, soft tissue techniques, craniosacral therapy, heat / cold therapy, as well as other techniques and procedures your treating physiotherapist determines beneficial. I understand that there is a possibility of symptom flare-up that can occur during and following physical and functional assessment.

I understand that following the assessment my therapist will discuss with me the proposed treatment plan in order to obtain my informed consent. I have the right to ask questions about my treatment and can withdraw my consent to any part of the assessment and treatment at any time.
Name *

First Name Last Name
Signature *
Date *

Month Day Year
Date
This section will be signed with the physiotherapist. No signature is required at this time.
Name

First Name Last Name
Signature

Clear
Date

Month Day Year
Date
Fees and Billing

By my signature below, I acknowledge that I understand the applicable fees and billing methods of NeuroLogic Physiotherapy, a copy of which I have read and reviewed (previous section) and that any appointment that needs to be cancelled must be done with 24-hours’ notice.
Name *

First Name Last Name
Signature *
Date *

Month Day Year
Date
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Neurologic Physiotherapy Intake Form

Fees and Billing

This section will be signed with the physiotherapist. No signature is required at this time.