Re:Treatment Consent and Disclosure Notice
If you are injured and not yet in treatment, your insurance company, a member of the Intact group of companies ("Intact") can assist you in promptly accessing the treatment you require. We have a network of independently owned treatment facilities and clinics with the ability to quickly assess you to meet your treatment needs. Intact has arranged for these companies to provide Intact clients with priority service. Intact hasno financial interest in any of these companies. All are paid in accordance with the Minor Injury Guideline or Professional Fee Guideline as published by the Financial Services Regulatory Authority of Ontario (FSRA), the regulatory body governing accident benefits claims. Your participation is completely voluntary and if you choose not to participate your entitlement to accident benefits is not affected. You do not need to make any commitment to treatment, may decline to participate at any time, and are free to choose a different treatment provider at any time. If you are concurrently involved in treatment that is similar to what is being recommended by this provider, it is your responsibility to advise this provider to avoid a duplication of services. Intact encourages you to speak to your family doctor and benefit from the experience and knowledge of your family doctor. I have read and understand the information above. I was provided with the opportunity to ask questions and all of my questions have been satisfactorily answered. I agree to participate in the services as provided by the provider. I understand that if I decide to withdraw at any time, my present and future entitlement to accident benefits will not be adversely affected.