TPh. 416-249-8668, Fax. 416-249-5794, Email:info@trinityrehab.ca
1 723 Kipling Ave. Unit#9, Etobicoke, ON M9R4E1
www.Trinityrehab.ca

MVA PATIENT INTAKE

PERSONAL INFORMATION

Last Name:

Address: (Unit & Street ):

Gender:

Cell #:

Family Physician:

Emergency Contact Telephone #:

I agree to receive e-newsletter and pro- motions via email:

Yes

First Name:

City:

E-mail:

Send Appointment reminder:

Yes

Physician Fax #:

How did you hear about us?:

Date of Birth:

Postal Code:

Telephone #:

Email:

Emergency Contact Full Name:

Referral Name or Source:

EXTENDED HEALTH INFORMATION

Do you have Extended Health Care Coverage?:

Yes

Do your parent(s) have Extended Health Care Coverage?:

Yes

Does your spouse have Extended Health Care Coverage?:

Yes

If you have checked off being covered under more than one persons benefits, please request a Secondary Coverage Form from us:

Yes

Insurance Company Name:

Telephone #:

Policy Holder’s Date of Birth (YYMMDD):

Plan / Policy #:

Fax #:

Group / ID #:

Policy Holder’s Name:

AUTOMOBILE INSURANCE INFORMATION

Insurance Company Name:

Telephone #:

Policy #:

Date of Issue of Policy:

City or Town of Branch Office (if applicable):

Fax #:

Claim #:

Were you at fault for the accident?

Yes

Adjuster’s Name:

Date of Accident (YYMMDD):

Name of policy holder same as:Applicant/OR

WORK INFORMATION

Employer:

Work Telephone #:

Occupation:

Work Fax #:

LEGAL INFORMATION

Law Firm:

Fax #:

Legal Representative:

Email:

Telephone #:

ACCIDENT PROFILE

Patient’s Name:

Date:

Were you working at the time of the accident?

Yes

Type of vehicle:

Date of Accident:

Amount of Damage:

Location of Accident:

How did the accident happen?

TREATMENT RECEIVED

DID YOU VISIT THE FOLLOWING?Please Select Both Checkbox.

Hospital

Family Physician

Have you received treatment at any other therapy clinic for this accident?

Yes

End Date:

Did you feel better after the treatment already received?:

*Name

Frequency:times / week

Translation needed:

Yes

Start Date:

Type of therapy:

Chiropractic

Physiotherapy

Massage o Exercises

Comments:

I hereby certify that I have read and understand the information recorded and verify that it is true and accurate.

HEALTH HISTORY FORM

In order to ensure optimum care in therapy, this form is to be completed by each patient. All information will remain confidential and be part of your therapy program. Feel free to ask any questions about the information being requested.

Current Medications

Conditions Meds treat:

Are you currently receiving treatment from another health care professional?

Yes

Surgeries?

Yes

Metal Implants (pins, plates, artificial joints?

Yes

What is the reason you are seeking physical/massage therapy?

Please include the location of any tissue or joint discomfort:

Application for Accident Benefits (OCF-1)

Return form to:For insurance companies: Add your contact and return instructions

Policy Number:

Claim Number:

Date of Accident:

Fill out this form if you are applying for benefits as a result of an automobile accident, and you haven't applied for benefits related to this incident before. You need to tell your insurance company within 7 days of your accident you plan to apply for benefits. If you can't do that within 7 days, let your insurance company know as soon as possible.

This Application for Accident Benefits form must be returned within 30 days after receipt. If you are unable to return it within 30 days, submit it to your insurance company and explain reason for the delay. Return the original form to the insurance company and make a copy for your records. If you require more information about the claims process, please visit FSRA's webpage.

Part 5 - Other Insurance

Do you, your spouse or anyone you are dependent on have any other benefit plan that covers you:(e.g. group benefits, extended health coverage, etc.)?

Yes

Part 6 - Authorization for Insurance to Directly Pay Service Provider

(Only applicable to applicants obtaining treatment/service from a licensed service provider)

I direct the insurer, including the Motor Vehicle Accident Claims Fund, to pay the licensed service provider directly for that portion of the approved goods and services specified in separate forms,Treatment Confirmation Form (OCF-23) and Treatment and Assessment Plan (OCF-18), that are not covered by extended/supplementary health insurance.

Applicants that have extended/supplementary health insurance responding to a claim may need to provide payment out of pocket before the extended/ supplementary health insurer reimburses the claimant.

Initials of Applicant or Substitute Decision Maker:

Part 7- Motor Vehicle Accident Claims Fund

The insurer that first receives your completed application for accident benefits is responsible for paying you the benefits to which you are entitled without delay. If you have not applied to the correct insurer your benefits will not be affected. It is the responsibility of the insurer to take the necessary steps to get the correct insurance company to respond to your claim. You should apply to the Motor Vehicle Accident Claims Fund only if no other insurance is available.The insurer that first receives your completed application for accident benefits is responsible for paying you the benefits to which you are entitled without delay. If you have not applied to the correct insurer your benefits will not be affected. It is the responsibility of the insurer to take the necessary steps to get the correct insurance company to respond to your claim. You should apply to the Motor Vehicle Accident Claims Fund only if no other insurance is available.

You and your substitute decision maker acknowledge that you have the responsibility to investigate and apply to all potential insurers to which the applicant may have recourse BEFORE submitting an application to the Motor Vehicle Accident Claims Fund (MVACF) at 222 Jarvis St., 7th Floor, Toronto, ON M7A 0B6. If you have any questions about your MVACF application contact: MVACF in Toronto at (416) 250-1422 or Toll Free at 1-(800) 268-7188.
You and your representative acknowledge that the application MUST INCLUDE a completed:

NOTICE OF COLLECTION OF PERSONAL INFORMATION FORM, signed and attached*

Form 3 – Section 6 MVACF Application for Statutory Accident Benefits, signed and attached*

Motor Vehicle Accident (Police) Report, attached.

Before the applicant can make an application for the payment of accident benefits from the MVACF
(* These forms are available at Motor Vehicle Accident Claims Fund)

I certify that I have read this part and understand that this application for accident benefits is not complete until the required forms are completed, signed and provided to the MVACF.

Name of Applicant or Substitute Decision Maker:

Date Signed:

Signature of Applicant or Substitute Decision Maker:

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About us

Media

Partnership

Core services

What We Treat

About us

Media

Partnership

Core services

What We Treat

About us

Media

Partnership

Core services

What We Treat

MVA PATIENT INTAKE

ACCIDENT PROFILE

HEALTH HISTORY FORM

Application for Accident Benefits (OCF-1)

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