• All fees are due at time of service and It is the patient's or guardian's responsibility to ensure the clinic is fully compensated for all services rendered.
• A 48-hour cancellation policy is in effect. Failure to show up for a scheduled appointment or arriving 30-minutes late will result in a no show fee equal to the visit fee will be added to the patient's account.
• Accounts over ninety days may be subject to collections and a twenty-five percent service fee.
• All insurance related information collected by our clinic can not be guaranteed to be accurate. Please contract your insurance company directly for accurate information in regards to your insurance plan.
• If your care is the result of a work injury or auto injury, the patient is still responsible for all outstanding fees owing to thenclinic for services rendered.

If you have read and agree to the clinic fees and policies above please sign below:

Patient Consent Form For Collection, Use and Disclosure of Personal Information

In this office, for their respective patients, Dr. Faisal Malik acts as the Privacy Information Officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate use and protection of your information. Attached to this consent form, we have outlined what our office is doing to ensure that: Only necessary information is collected about you; Information is shared only with your consent; storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols; Our privacy protocols comply not only with privacy legislation, but with the standards of the Ontario Chiropractic Association, and the law. Do not hesitate to discuss our policies with Dr. Faisal Malik or any member of our office staff. Please be assured that every staff member in our office is committed to ensuring that you receive the best quality health care. This office will collect, use and disclose information about you for the following purposes: To offer and provide treatment, care and services for all chiropractic health care issues. To deliver safe and efficient patient health care and to identify and ensure continuous high quality service. To assess your health care needs and to advise you of treatment options. To enable us to contact you and maintain communication with you, for purposes of distributing health care information and booking/confirming appointments for treatments. To maintain communication with you through email newsletters. To invoice for goods and services, to process credit card payments, and to collect on unpaid accounts. To communicate with other treating health care providers, including your pharmacist/pharmacy. To communicate with laboratories in cases where laboratory services are required. For teaching and demonstrating purposes on an anonymous basis. To complete and submit chiropractic claims for third party adjudication and payment. To comply with legal and regulatory requirements, including the delivery of patients' charts and records to the Ontario Chiropractic Association in a timely fashion, when required, according to the provisions of the Personal Health Information Protection Act (PHIPA) . To comply with agreements/undertakings entered into voluntarily by the member with the Ontario Chiropractic Association, including the delivery and/or review of patients' charts and records to the Association in a timely fashion for regulatory and monitoring purposes. To deliver your charts and records to the Chiropractic insurance carrier to enable the insurance company to assess liability and quantify damages, if any. To assist this office to comply with all regulatory requirements and to comply with the law. By signing the section of the Patient Consent have consent you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of the Personal Health Information Protection Act (PHIPA) for the purposes of the Ontario Chiropractic Association fulfilling its mandate under the PHIPA, and for the defense of a legal issue. Our office will not, under any condition, supply your insurer with your confidential medical history. In the eventthat this kind of a request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use or disclosure of your personal information at any time, and we will explain the ramifications of the decision, and the process. 

I have reviewed the Privacy Policy that explains how this office will use my personal information, and the steps this office is taking to protect my information. I know that this office has a Privacy Policy, and I can ask to see the Policy at any time. I agree that Dr. Faisal Malik and his staff can collect, use and disclose personal information about myself as set out in the attached information about the office's privacy policies.

Electronic Transmission Authorization and Consent Form

Instructions: This form must be filled out when claims are submitted electronically by the provider on the patient's behalf. Please retain this form in the patient's file for verification purposes for two years following closure of the patient file. 

Consent to Collect and Exchange Personal Information

Message to the Plan member, Spouse and/or Dependent regarding Personal Information

Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and/or plan abuse.

Authorization and Consent

I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes.

• I authorize the insurer and or plan administrator and their service provider(s) to: use my personal information for the above purposes.
• exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.
• exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.
• exchange personal information for the above purposes electronically or in any other manner.

I understand that personal information may be subject to disclosure to those authorized under applicable law. I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.

Additional Consent Applicable to Plan Members Only

I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and payinga benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider.

In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose.

I hereby request and consent to therapeutic massage treatments on me by the Registered Massage Therapist.

I understand and am informed of the benefits of massage therapy, as well as the possible side effects, risks, and the consequences of not having such treatment. I further understand that I do not expect the Massage Therapist to be able to anticipate and explain all risks and complications, and I wish to rely on the Therapist to exercise judgment during the course of the treatment, which the Therapist feels at the time, based upon the facts then known to be in my best interest. All female patients must inform the massage therapist if they know or suspect that they are pregnant.

I have had the opportunity to ask questions and I am aware of my right to modify or stop the assessment/treatment at any time and/or refuse, alter or withdraw this consent at any time. Treatment times include assessment time; time spent getting on and off ofthemassage table, and remedial exercise if required. I understand that payment for services received is my responsibility and must be made at time of service. If my claim is to be submitted directly to an outside agency for payment, and for some reason the third party payer denies the claim and/or refuses to pay all or partial the full amount billed, I am responsible for paying the amount outstanding.

I am aware of the cancellation policy that requires 48 hours notice to cancel a massage appointment. Appointments that are missed will be billed a missed appointment fee (50% of full price).

I intend this consent to apply to all my present and future Massage Therapy visits.