MOTOR VEHICLE INSURANCE (MVA)
If you have been involved in a Motor Vehicle Accident, your insurance will provide you with the Accident Benefits Application Package. You will be required to complete the following forms included in the package:
1) Application for Accident Benefits (OCF-1)
Fill out this form when you are applying for benefits for the first time as a result of an accident, including if you are injured and are applying for income replacement benefits. Return this form to the insurance company within 30 days after receiving the package and make a copy for your records.
2) Employer’s Confirmation of Income (OCF-2)
If the insurance company asks you to, please give this form to your employer. This form is completed by you or your representative and by your employer. If you had more than one employer during the past 52 weeks, it may be necessary for each employer to complete a separate form. Your insurance company may ask for other proof of income.
3) Disability Certificate (OCF-3)
If the insurance company asks you to, please fill out the first section and give this form to your health practitioner (chiropractor, dentist, occupational therapist, nurse practitioner, optometrist, physician, physiotherapist, occupational therapist, speech language pathologist or psychologist). This form is completed by you or your representative and by your health practitioner.
4) Permission to Disclose Health Information (OCF-5)
If the insurance company asks you to, please complete this form. The insurance company requires your medical information in order to correctly determine your eligibility for benefits. Health professionals require your written permission to disclose this information to the insurance company.
What North Ajax Rehab & Sports Injury Clinic must complete for you:
5) Pre-approved Framework Treatment Confirmation Form (OCF-23/198)
After your assessment visit, we will complete this form and send it to your Motor Vehicle Insurance Adjuster for approval. After the insurance company reviews your complete application package, you will be contacted about the benefits you are entitled to receive. After we receive approval for treatment, we will contact you and book your appointments according to the treatment plan.
There is no cost to patients suffering from a Motor Vehicle Accident that have been approved for 100% coverage with Motor Vehicle Insurance. Treatment services will be billed directly to the Motor Vehicle Insurance.
Note about Private Insurance:
If you, or your spouse/parent have private insurance, please bring us a completed and signed Extended Health Claim form. We must bill your private insurance first. You must exhaust your private insurance before your Motor Vehicle Insurance will pay.