MVA Intake Form - Back on Track Physiotherapy

Client Personal Information

Select Clinic Location *

First Name *

Last Name *

Date of Birth *

Accident Date *

Email Address *

Phone Number *

Home Address *

Name of Policy Holder *

Same as Patient Other

Auto Insurance Information

Claim Number *

Policy Number *

Insurance Company *

Insurance Company City

Insurance Company Address

Adjuster's Name *

Adjuster's Phone

Adjuster's Email

Adjuster's Fax

Treatment Area / Symptoms

Please describe your treatment area and symptoms *

Have you been assessed by someone else? *

Yes No

If yes, assessed by (1):

If yes, assessed by (2):

Do you have legal representation? *

Yes No

If yes, name of legal firm:

Extended Health Benefits

Important: As per FSCO, we must bill your extended health prior to billing your car insurance company. We will require a statement from EHB to submit to MVA in order for them to cover the difference.

Do you have Extended Health Benefits? *

Yes (Complete sections below) No

Primary Insurance Benefits (If Applicable)

Name of Policy Holder

Same as Applicant Other

Policy Holder's Date of Birth

Doctor Referral Name

Insurance Company Name

Policy/Claim Number

ID/Certificate Number

Expiry/Renewal Date

Limits & Percentage

Secondary Insurance Benefits (If Applicable)

Name of Policy Holder

Same as Applicant Other

Policy Holder's Date of Birth

Doctor Referral Name

Insurance Company Name

Policy/Claim Number

ID/Certificate Number

Expiry/Renewal Date

Limits & Percentage

OCF-1 Submission

Your MVA insurer will not consider payment of any invoices without receipt of a completed OCF-1. Any denied payment due to incomplete OCF-1 will be your responsibility.

Have you submitted your OCF-1 form? *

Yes No

If yes, date OCF-1 was sent:

MVA Cancellation Policy and Payment 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.

Although we have always had a cancellation policy, circumstances with MVA claims have caused us to reinforce this policy with a signed agreement. 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

Your car insurance will not be billed, nor will they pay for this charge. This will be billed and must be paid by you for you to continue to be treated under your claim. Under certain circumstances management may waive this fee.

It is also imperative that when you submit to your EHB company, payment is made to us immediately upon receiving those funds along with the statement. This will then allow us to bill your auto insurance company and not cause any delays with treatment.

Agreement Required

By checking the box below, you understand and agree to the cancellation and payment policy.

I have read, understand, and agree to the MVA Cancellation Policy and Payment Policy. *

Patient's Full Name (as signature) *

Date *

Motor Vehicle Accident Client Information

Dear Patient:

After experiencing a Motor Vehicle accident, we at Back on Track Physiotherapy know that the process can be overwhelming, so we have decided to provide some general but important information for this process and what you can expect from your Back on Track Physiotherapy team:

You will receive a package from your car Insurance. This package is called "Accident Benefits Package" and/or "OCF1." This package must be completed and sent to your Insurance within 30 days of you receiving it. Before you send it off, please provide a copy to your attending Back on Track Physiotherapy location so we can keep a copy in your file in case your adjuster has any future questions.
If you do not have all your Insurance information at the time of your assessment you are to provide this on your 2nd visit. This information includes your policy number, claim number, adjuster name and insurance company name.
By law, patients must provide any attending Clinic with their Extended Health Benefits (EHC/Work Benefits/Group Benefits/Private Insurance) information.
Back on Track Physiotherapy will ask you to pre-sign Claim forms so that we can submit to your Extended Health Carrier twice a month for reimbursement. After approximately 2 weeks of our submission, you will receive payment from your Extended Health carrier by mailed cheque or direct deposit. You are responsible to then forward payment and statement to your attending location. (Without this, we cannot submit to your Auto Insurance for the remaining balance.)
If you do not provide all the necessary or correct information, you will then be held responsible for any monies outstanding on your account.

If you have any questions or concerns, please do not hesitate to ask our staff.

I have read and understand the MVA client information provided above. *

Patient's Full Name (as signature) *

Date *

Motor Vehicle Accident (MVA) Intake Form

Client Personal Information

Auto Insurance Information

Treatment Area / Symptoms

Extended Health Benefits

Primary Insurance Benefits (If Applicable)

Secondary Insurance Benefits (If Applicable)

OCF-1 Submission

MVA Cancellation Policy and Payment Policy

Motor Vehicle Accident Client Information

Health History

Submit Your MVA Intake Form