New Patient Intake — Alberta Physical Therapy Clinic

Name*

First Last

Alberta Health Card Number*

Family Physician*

Birth Date*

Address*

Street Address City Province Postal Code

Phone*

Email*

Description of problem for which you are currently seeking treatment:*

Is this the result of a Motor Vehicle Accident?*

Yes

No

The Alberta Physical Therapy Clinic is authorized to treat injuries as a result of a motor vehicle accident. If you have a valid MVA claim, we may be able to bill the insurance directly for your treatment costs. If your treatment costs are not covered under a claim, you are responsible for these charges.

Diagnostic Treatment Protocols Regulation Interpretative Guide is intended to streamline the process for both patients and primary health care practitioners. Under the DTPR, primary health care practitioners do not have to seek approval from the insurer to treat minor injuries and receive payment, although they are required to notify the insurer of the claim. Primary health care practitioners will then be able to bill the auto insurer directly for all treatment services outlined in the DTPR, unless covered by Alberta Health Care Insurance.

Date of accident*

Vehicle Insurance Company*

Insurance Company's Phone Number*

Injury Adjuster*

Name of Policy Holder*

Claim Number*

Policy Number*

Insurance Company's Address

Street Address City Province Postal Code

Did this injury occur at work?*

Yes

No

The Alberta Physical Therapy Clinic is an authorized WCB provider. If you have a valid WCB claim, we will bill them directly for your treatment costs. If your treatment costs are not covered under a claim, you are responsible for these charges.

You must have completed a “Workers Report of Injury or Occupation Disease” form in order to have your claim considered by WCB (this is different from the form your employer fills out). If you have not done this, they can be found on the Workers Compensation Board Alberta Website.

If you are uncertain as to the status of your claim, please contact your case manager or ask our staff, we may be able to help you to verify the status of your claim.

Name of Employer*

Employers Phone Number*

Employers Address*

Street Address City Province Postal Code

Date of Injury*

WBC Claim Number*

Are you claiming your treatment to a disability insurance?*

Yes

No

Insurance Company*

Claim Adjuster*

Claim Number*

Insurance Company's Phone Number*

Insurance Company's Address*

Street Address City Province Postal Code

Are you a Veteran?*

Yes

No

Veterans Affairs K Number

Canadian Armed Forces ID Number

Do you have extended health care benefits that covers physical therapy?*

Yes

No

Name of Insurance Company*

Name of Primary Insurance Holder*

Primary Insurance Holders Birth Date*

Group Number*

ID Number*