Massage Therapy Intake Form

Motor Vehicle Accident Injuries
If your injuries are the result of a motor vehicle accident please complete the following?*

YesNo
Date of Accident

MonthDayYear
Policy Number:
Claim Number:
Insurance Company:
Address of Insurance Company:
Name of Policy Holder:
Date of Birth of Policy Holder (if not client):

MonthDayYear
Date
Name of Adjuster:
Address:
Phone Number:

Area CodePhone Number
Fax Number:

Area CodePhone Number
Case Manager:
Extended Health Insurance?

YesNo
If yes, name of company:
Group Policy / Plan #:

Fees and Billing
This clinic is not covered by OHIP. You are responsible for any charges incurred at this clinic. The fee schedule is available at reception. Payment must be made directly to Lifemark Neurologic Physiotherapy at each visit. Payments can be made by cash, cheque, debit card, Visa or MasterCard. Most extended health plans now cover massage therapy treatment. You do not require a doctor's referral to attend massage therapy; however, your insurance company may require one to process your claim. If you have any specific questions about our rates or your massage therapy coverage, please do not hesitate to ask us.

Lifemark NeuroLogic Physiotherapy Cancellation and No Show Policy

A significant amount of time is set aside for your appointment, and without prior notice the appointment slot cannot be filled. Thus, a 24-hour notice is required to cancel your appointment. After hours, a message may be left on our answering machine. Patients who do not give 24 hour notice and do not have a legitimate excuse (i.e. illness or inclement weather, etc.) will be charged the treatment fee. This charge is not covered by insurance companies. It will be the responsibility of the patient to pay this charge.

If You Are Hurt In a Motor Vehicle Accident (MVA)

If you have injuries stemming from a motor vehicle accident you must first complete and submit an OCF 1 form to your adjuster.

Billing for MVA Not-Catastrophic and Minor Injury Guidelines (MIG) Insurance Claims Upon Approval of a Treatment Plan
- Our clinic policy is you pay us upfront and submit for reimbursement from your EHI and MVA insurer. Our clinic rate for massage treatments are $115/hr+tax (1hr). As the FSCO rate is $58.19/hr+tax, there is a rate difference discrepancy that will not be reimbursed by you MVA insurer. You may pursue treatment elsewhere and not be required to pay upfront nor pay this discrepancy of rate difference.
Billing for MVA Catastrophic Insurance Claims Upon Approval of a Treatment Plan
- Our clinic policy is you pay us upfront and submit for reimbursement from your EHI and MVA insurer. Our clinic rate for massage treatments are $115/hr+tax (1hr). As the FSCO rate is $89.07/hr+tax, there is a rate difference discrepancy that will not be reimbursed by you MVA insurer. You may pursue treatment elsewhere and not be required to pay upfront nor pay this discrepancy of rate difference.
Extended health insurance coverage and reimbursement
- If you have available extended health insurance, it is our clinic’s policy that you pay upfront for all assessment and treatment costs at our clinic rates. To be reimbursed, you will first submit your paid invoice to your available EHI provider(s). If there is a portion that your EHI does not cover you would then provide us the EHI statement(s) showing what your EHI paid so that we can fax that proof to your MVA adjuster. We require these statements within 30 days following the treatment services (within 60 days if you are billed monthly due to in-home treatment service) so that we can bill your MVA insurer. Once we receive this reimbursement it will be extended to you in form of cheque. If and when you can provide paper proof that all available EHI is exhausted (we are required to fax this proof to your MVA adjuster) our clinic will direct payment towards your MVA insurer.
**Please ask reception to review our Fee Schedule which outlines the rate difference between our clinic rates and the MVA maximum hourly rates approved.
I have read and acknowledged this policy*

Yes

Privacy Policy

The Lifemark Neurologic Physiotherapy Privacy Policy is available at the front desk or at this link. This provides a more detailed description of the use of this information. Please ask the receptionist for a copy.

I understand that to provide me with massage therapy services, Lifemark Neurologic Physiotherapy will collect personal and health information about me. It is used primarily to deliver safe and efficient care, to communicate on your behalf with other health care providers and complete and submit claim forms for insurance adjudication and payment.

I understand how the Privacy Policy applies to me. I have been given a chance to ask any questions I have about the Privacy Policy and they have been answered to my satisfaction.

I agree to Lifemark Neurologic Physiotherapy collecting, using and disclosing personal information about me as set out above and in the Lifemark Neurologic Physiotherapy Privacy Policy. I am aware that I have access to this information and that I can withdraw this consent at any time.

I understand that Lifemark Neurologic Physiotherapy is considered the Health Information custodian and not my individual therapist.
Name*

First NameLast Name
Signature (click, drag and draw signature with mouse cursor)*
Date*

MonthDayYear
Date
Consent for Massage Therapy Assessment - Our clinic is committed to ensuring you receive quality, informed care.

I consent to a comprehensive I consent to a comprehensive massage therapy assessment, which may consist of manual techniques, therapeutic exercises, electrotherapeutic modalities, acupuncture, soft tissue techniques, craniosacral therapy, heat / cold therapy, as well as other techniques and procedures your treating massage therapist determines beneficial. I understand that there is a possibility of symptom flare-up that can occur during and following physical and functional assessment.

I understand that following the assessment my health care provider will discuss with me the proposed treatment plan in order to obtain my informed consent. I have the right to ask questions about my assessment/treatment and can withdraw my consent to any part of the assessment/treatment at any time.
Name*

First NameLast Name
Signature (click, drag and draw signature with mouse cursor)*
Date*

MonthDayYear
Date
Fees and Billing

By my signature below, I acknowledge that I understand the applicable fees and billing methods of Lifemark Neurologic Physiotherapy, a copy of which I have read and reviewed (previous section) and that any appointment that needs to be cancelled must be done with 24-hours’ notice.
Name*

First NameLast Name
Signature (click, drag and draw signature with mouse cursor)*
Date*

MonthDayYear
Date
Should be Empty:

Massage Therapy Intake Form

Fees and Billing