Client Agreement Core Connections Physiotherapy

Client Agreement Regarding Payment

To be completed prior to your appointment

"*" indicates required fields

Core Connections Physiotherapy is a private, physiotherapist-owned practice and, therefore, we do not bill O.H.I.P. for the treatment we provide. We can however, direct bill your Extended Health Care Plan. Please provide details below.

Primary Insurance

Name of Policy Holder:*

First Last

Date of Birth*

Insurance Company:*

Policy/Plan #:*

Subscriber ID/Certificate #:*

Place of Employment:*

Relationship to Policy Holder:*

If your Extended Health Care cannot be billed directly , it is your responsibility to pay Core Connections Physiotherapy directly and submit your Extended Health Care benefit for reimbursement . I acknowledge responsibility for payment

Signature

Date

Client/Guardian

First Last

Date

Phone

This field is for validation purposes and should be left unchanged.