Patient Intake Form

*By adding your email, we will send you appoitnment reminders, your home exercises and occasional newsletters - your email will never be shared with any other organization.

I understand that the clinic requires reasonable notice for cancellation of appointments. I also understand that I may be charged if I do not attend for scheduled appointments. We define reasonable notice as 24 HOURS, with exceptions for emergency, adverse weather and unexpected illness

I understand that payment for services received at the clinic is my responsibility, and fees are payable at the time of my appointment. I understand that the fees per visit for these services are:

Assessment & Initial Visit $140 Follow up Treatment sessions $90 

2.     I consent to being assessed by a Pure Physiotherapist which may include treatment. I will be informed of the treatment Pros and Cons by the Physiotherapist and am also aware of my right to withdraw my consent, verbally, to treatment, at any time.

3.     I have read / understood the Clinic’s 24 hour cancellation policy.

4.     If any third party payer (insurance company) refuses to pay for my claim, I accept responsibility for any unpaid balance on my account.

Note to client: We want your informed consent. We want you to understand what we do with the personal health information we collect about you. Please ensure that you have read and understood our written statement, “Our Privacy Commitment to You”. If you have any questions, please ask.

I have reviewed the Pure Physiotherapy’s written statement on the collection, use and disclosure of personal health information. I understand how the written statement applies to me. I have been given a chance to ask questions about the Pure Physiotherapy’s privacy policies and they have been answered to my satisfaction.

I understand that Pure Physiotherapy will only collect, use or disclose my personal health information with my express or implied consent, unless a collection, use or disclosure without consent is permitted or required by law.

I understand that I can withdraw my consent at any time by contacting: Joanna Nelken I agree to Pure Physiotherapy collecting, using and disclosing personal health information about me as set out above and in the written statement. 

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.

Provider: PURE PHYSIOTHERAPY

Address: 1136 Lorne Park Road

City/Province: Mississauga, Ont.

Postal Code: L5H 3A4

Phone Number: 905-891-7873

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

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.

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 paying a 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 assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/ or supplies provided. I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment. I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.