if you choose to pay upfront and submit yourself to the extended health insurance, providing insurance details is not necessary.

if you do not have extended health insurance, you are not required to complete the insurance section below.

Agreement Overview

This agreement outlines the financial responsibilities of the patient and the terms for services provided at Trinity Rehab & Wellness ("The Clinic"). By signing this document, the patient acknowledges understanding of their financial obligations related to treatment, services or medical devices.

1. Payment for Services: The patient agrees to pay for all services rendered by Trinity Rehab & Wellness, including but not limited to physiotherapy, chiropractic, acupuncture, osteopathy, podiatry, massage therapy and rehab or exercise sessions, assessments, treatment plans and medical devices provided. Payment will be required for each session at the time of service, unless otherwise specified.
NOTE: The Ontario Health Insurance Plan (OHIP) does not provide coverage for our services.

2. Insurance Claims: If applicable, the patient authorizes Trinity Rehab & Wellness to submit claims to their insurance provider on their behalf. However, the patient remains responsible for any amounts not covered by insurance, including but not limited to co-pays, deductibles, and denied claims.
The patient understands that the amount reimbursed by the insurance company is not guaranteed, and any balance owed for services rendered is the patient's responsibility.

3. Payment Methods: The patient agrees to make payments via the following accepted methods:

Credit Card (Visa, MasterCard, American Express)

Debit Card

Cash

E-transfer

Cheque

4. Missed Appointments and Cancellations: The patient agrees to provide a minimum of 24 hours' notice for cancellations or rescheduling of appointments. A missed appointment or late cancellation will incur a fee of $40.00 or equivalent to the full cost of the session, unless otherwise stated by the clinic.

5. Payment Plans: If the patient is unable to pay the full amount at the time of service, they may request a payment plan. The clinic will consider payment plan options on a case-by-case basis, which may include installment payments over a mutually agreed-upon.

6. Collection of Unpaid Balances: If the patient fails to pay for services rendered and the balance remains unpaid for 30 days, Trinity Rehab & Wellness reserves the right to refer the debt to a collection agency. The patient agrees to pay all collection fees, legal fees, and any other costs associated with the recovery of outstanding balances.

7. Consent to Treatment: The patient understands that by signing this agreement, they consent to the treatment and services provided by Trinity Rehab & Wellness and agree to pay for the services rendered in accordance with the terms of this agreement.

8. Third-Party Responsibility: If the patient is receiving services as a third-party beneficiary (e.g., spouse, dependent, or employer-sponsored plan), the patient or their legal guardian agrees to accept full responsibility for payment in the event the third-party payer does not cover the full cost of services.

9. Financial Responsibility for Minors: If the patient is a minor, the parent or legal guardian of the minor acknowledges responsibility for the payment of all services rendered.

10. Acknowledgment: By signing this agreement, the patient acknowledges and agrees to the terms outlined above. The patient agrees to be financially responsible for all charges related to the services provided by Trinity Rehab & Wellness, and understands that this agreement will remain in effect for the duration of their treatment.

Note: To be completed only by patients desire direct billing to their insurance companies

Purpose:


The personal information collected and disclosed about you is used by the insurer, plan administrator, affiliates, and service providers for purposes such as assessing claim eligibility, underwriting, auditing, fraud investigation, and administering the group benefits plan, including data management and analytics.


Authorization and consent:


I authorize my healthcare provider, Trinity Rehab & Wellness, its staff, and authorized personnel to collect, use, and disclose my personal information regarding services or medical devices, including electronic and manual claims, to the insurer/plan administrator and their service providers. I also authorize these parties to exchange personal information with relevant individuals or organizations, including healthcare professionals, investigative agencies, insurers, reinsurers, and government benefits administrators, for the purposes outlined above. I understand that personal information may be disclosed as required by law. I agree that a photocopy or electronic version of this authorization is as valid as the original.


Fraud and Overpayment Disclosure:


In the event of suspected fraud or plan abuse, I acknowledge that the insurer/plan administrator and their service providers may disclose relevant information to law enforcement, regulatory bodies, medical suppliers, and other insurers for investigation and prevention. I understand that submitting fraudulent claims is a criminal offense. If an overpayment occurs, I authorize recovery from future benefits and the exchange of information with relevant parties, including credit agencies and my benefit plan sponsor.


Benefit Assignment:


I assign eligible claim benefits to Trinity Rehab & Wellness and authorize the insurer/plan administrator to make payments directly to them. If claims are declined, I remain responsible for payment to the provider.

I acknowledge the insurer/plan administrator is not obligated to accept this assignment, and any benefit payment made according to this form discharges their obligations.

I understand that this assignment applies to all eligible claims submitted by Trinity Rehab & Wellness, and I may revoke it at any time by notifying the insurer/plan administrator in writing. If I am a spouse or dependent, I confirm I am authorized to execute this assignment on behalf of the plan member.


Acceptance of Terms :

I accept the above terms and conditions.

To Administrative Staff:

All information contained herein is protected by privacy laws including the Personal Information Protection and Electronic Documents Act (PIPEDA) and all the corresponding provincial legislation. All users agree to protect the personal health information contained herein from unauthorized use, disclosure, loss, theft, or compromise in accordance with the above noted laws and with at least the same care employed to protect their own confidential information. Any unauthorized access, disclosure or use of this information is illegal.

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.