Motor Vehicle Accident History Form (Page 2 of 2) in pdf

Do you have private health insurance coverage for Chiropractic and/or Massage?

Yes

(The easiest way to find out the answers is to call

If yes , we need the following information about your benefits.

your provider (i.e. Greenshield, Blue Cross, Manulife, etc) directly and have them give you the following information.

*Health Insurance Company : ______________________________ * Policy # _____________________

*Name of Insured (Policy Holder) __________________________ Member # ____________________

*What is your total amount of yearly coverage for Chiropractic $ ____________ Massage $ ___________

*How much coverage is remaining for this year, for Chiropractic $ __________

Massage $ ___________

What percentage of payment, or specific amount per treatment, does your plan pay?

(i.e. 80% coverage, $15.00 per visit, etc): _______________________________________________________

*Does your benefits plan pay for treatment if you have been in a Motor Vehicle Accident?

Yes

* required field

FINANCIAL POLICY FOR AUTOMOBILE INSURANCE CLAIMS

If you have been injured in a Motor Vehicle Accident and are filing a claim with an automobile

insurance company, please notify the staff and doctor immediately. Your insurance adjuster

should send you an “Application for Accident Benefits” (OCF – 1) along with a “Permission to

Disclose Health Information” (OCF 5), a “Disability Certificate” (OCF - 3/59) and a “Treatment

Plan” (OCF – 23) for your doctor to complete, outlining your injuries and required therapy. According

to government legislation, the application must be completed and returned to the insurance company

before any treatment can be approved. Please complete this package and return it to your claims

adjuster as promptly as possible in order to expedite approval for your claim and payment for your

treatment.

FSCO (Financial Services Commission of Ontario) requires that we confirm the identity of every MVA

claimant. We accept the following pieces of identification and will keep a photocopy in your file – Valid

Driver’s License, Passport, Health Card, or Ontario Photo Card.

If you have private health benefits which cover accident injuries, payment for your treatment is due at

each appointment until the benefits are exhausted. If for any reason your claim is denied, you (the

patient) will be responsible for paying the entire balance owing for goods and services that have been

rendered.

I, _________________________________ have read and fully understand the above financial policy

related to motor vehicle accident claims.

Patient Signature: _____________________________________

Date: _____________________

Motor Vehicle Accident History Form Page 2