Motor Vehicle Accident (MVA) Information Form

Name*

First Last

Email*

Phone

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of incident*

Health Card #

MV Insurance Company*

MV Insurance Policy Number*

Claim Number*

MVA Case Worker

First Last

MVA Case Worker Email

MVA Case Worker Phone

Do you have Personal Health Insurance?*

Yes
No

Policy #*

Member ID*

Name of Policy Holder*

Policy Holder DOB*

Employer*

Employer Contact Name

First Last

Employer Contact Phone

Employer Contact Email

Payment Policy*

I agree to the payment policy

MSI does not cover any of MOVE’s services; therefore you, the patient, are responsible for payment of services rendered, should your Motor Vehicle Insurance not approve payment.

Payment is due at the time of your appointment. Many patients have Extended Health Care (EHC) Benefits to offset the cost of our services. We direct bill most, if not all EHCs. It is your responsibility to know the details of your own plan. If you are covered under more than one policy, please note that we will only bill the primary policy. (MOVE Physiotherapy reserves the right to refuse direct billing to any insurance company).

Please Note: If your claim is refused or denied by your Motor Vehicle Insurer, you are responsible for all payments for services rendered. These fees may include, but are not limited to the following: treatment fees, product fees and fees for any forms completed during treatment.

Any outstanding accounts after 30 days, will be charged to the credit card on your file, or sent to collections, should payment be refused.

Signature*