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MVA Claim Information & Authorization

Use this form to provide details about your recent motor vehicle accident and your insurance coverage details.

PATIENT INFORMATION

Gender

Cogent Physical Rehabilitation Center staff may leave phone messages at provided numbers for confirmation or changes to your scheduled appointments.  (Please check the phone numbers below if you do not want us to leave phone messages)

Do not leave phone messages on these phone numbers

Check all that apply.

By providing your email, you are consenting to email communication from Cogent Physical Rehabilitation Center such as appointment reminders, statements, invoices, exercise instructions, newsletters & commercial electronic messages.

ACCIDENT INFORMATION

Date of Accident
Injured Area (choose all that apply)

INSURANCE INFORMATION

The laws in Ontario require that all invoices related to your treatments for injuries sustained in a Motor Vehicle Accident be submitted to your private/employer health insurance provider if available.

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

AUTO INSURANCE INFORMATION

LEGAL REPRESENTATIVE

TERMS OF SERVICE

  • I hereby authorize Cogent Physical Rehabilitation Center to collect and release medical records, copies of treatment plans and financial and any other information related to my claim to above mentioned legal representative and third party payers (Private Insurance payer & Car Insurance).

  • I understand that I am legally responsible for providing Cogent Physical Rehabilitation Center with all information for my claim including any updates.

  • I direct all third party payers to pay Cogent Physical Rehabilitation Center directly for fees related to services provided for my injuries to this claim.

  • In the event of any settlement or agreement with insurance company, I will ensure all the unpaid services at Cogent Physical Rehabilitation Center for my injuries are paid in full including any interest. I understand that I will remain responsible for any unpaid balance. 

Please check the below box if you agree to our terms of service above.

SIGN & SUBMIT

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