EHC Intake Package

Extended Health Care Direct Billing Enrollment Form

5-10 minutes to complete
Secure & Confidential

Patient Information

Please provide your personal details

Primary Insurance Benefits

Secondary Insurance Benefits

Please Note: We are currently unable to bill secondary coverage directly. This information is for our records only.

Direct Billing Authorization

Credit card information for unpaid balances

I hereby give permission to Back on Track Physiotherapy to direct bill my insurance company. I am aware that the payment will be sent directly to Back on Track Physiotherapy. I am also aware that if any services are not covered by the insurance company or if any payment is not received from the insurance company, my account is my financial responsibility. I also understand that it is my responsibility to understand the parameters of my plan, whether a Physician referral is required, what percentage is covered & the annual limit.

I hereby agree to have the balance applied to my credit card. I understand my credit card will only be billed for unpaid amounts following 60 days of treatment. An itemized receipt will be emailed, if provided, or mailed to my address on file.

Your credit card information is kept secure and confidential. It will only be used to process unpaid balances after 60 days.

Extended Health Coverage Details

For clinic use - coverage verification

Note: This section will be completed by our clinic staff when we verify your coverage. You may leave these fields blank, or fill in any details you know about your coverage.

Physiotherapy Coverage

Chiropractic Coverage

Massage Coverage

Acupuncture Coverage

Compression Socks Coverage

Custom Bracing Coverage

Appliances Coverage

Orthotics Coverage

Other Coverage (if applicable)

Refusal to Disclose Insurance Information

Optional - Only complete if you do not wish to provide insurance details

I, [Patient Name], do not wish to disclose my extended health care benefits insurance information to Back on Track Physiotherapy. I am aware that the reason for this request is to keep track of my coverage and agree that I will personally keep track and be responsible for my account.

Cancellation Policy

Please review and acknowledge our cancellation policy

Important Cancellation Policy

We understand that unplanned issues may come up and you will need to cancel an appointment. If this happens, we respectfully ask that you notify us at least 24 hours prior to your appointment time.

Our therapists want to be available to meet your needs as well as the needs for all of our patients. When a patient does not show up for a scheduled appointment, another patient loses the opportunity to be seen.

If we are not provided with the appropriate notice, you will be responsible for a Missed Treatment charge of $50.00.

For any Missed Massage Treatment, you will be charged in accordance with the RMTAO as follows:

  • 2nd missed massage – 50% of the massage fee
  • 3rd missed massage – 100% of the massage fee

This charge will not be billed to any third-party payors, you will be billed, and it must be paid by you for you to continue to be treated under your claim. Under certain circumstances management may waive this fee.

By submitting this form, you agree to all terms and policies outlined above.