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WSIB Claim Information & Authorization

Patient Information

Your 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 number:

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

WORK INFORMATION

ACCIDENT INFORMATION

Date of Accident
Body Part Affected (Choose all that apply)

ADJUDICATOR INFORMATION

CASE MANAGER INFORMATION

LEGAL REPRESENTATIVE

Terms of Service

  • I hereby authorize Cogent Physical Rehabilitation Center to collect and release medical records and any other information related to my claim to the above mentioned legal representative, my family doctor and the Workers Safety and Insurance Board (WSIB).

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

  • WSIB will pay a standard fee for medical services related to your approved claim & requires a minimum number of treatment sessions based on applicable program of care.

  • In the event of denial of your claim or non-compliance with the treatment plan causing your claim to disqualify, WSIB will contact you not the clinic. It will be your responsibility to inform Cogent Physical Rehabilitation Center of such decision.

  • I understand that I am responsible for all unpaid fees.

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

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

SIGN & SUBMIT

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