THE BRIGHT PHYSIO & MINDFULNESS MASSAGE
Unit #105, 4904 30 Avenue, Beaumont, Alberta T4X 3G3 | Phone: 780-737-1019 | Fax: (844) 777-1796 | Email: thebrightphysio@gmail.com | Website: www.thebrightphysio.ca
CLINIC CONSENT & FINANCIAL POLICY FORM
Please read this form carefully. By signing at the end, you acknowledge that you have read, understood and agree to the applicable
clinic policies described below.
1. Consent for Payment & Billing Policies
The Bright Physio & Mindfulness Massage Inc. provides physiotherapy, massage therapy, chiropractic services, acupuncture
services and related clinic services that may be eligible for coverage through extended health benefits, Workers' Compensation
Board - Alberta (WCB-Alberta), automobile insurance/MVA benefits, or other third-party payers, depending on eligibility and
individual plan coverage.
Payment is due at the time services are provided unless another billing arrangement has been approved by the clinic. Direct billing to
insurance companies is offered as a convenience when available; however, direct billing is not a guarantee of coverage or payment.
Some insurance plans may require the patient to pay upfront. In such cases, the clinic will provide a receipt that may be submitted to
the insurer for reimbursement.
The patient is responsible for understanding their insurance coverage, including benefit limits, deductibles, co-payments, referral
requirements and services or products that may not be covered.
If an insurer or third-party payer denies, reduces or reverses payment for any reason, the unpaid balance remains the responsibility
of the patient or financially responsible party.
2. WCB-Alberta & Motor Vehicle Accident Claims
For eligible workplace injuries, the clinic may submit approved treatment fees and required reports directly to WCB-Alberta.
For eligible Motor Vehicle Accident (MVA) claims, the clinic may submit treatment invoices, reports and required documentation to
the applicable automobile insurer in accordance with Alberta requirements.
Information reasonably necessary for assessment, treatment, billing, reporting and claim administration may be provided to
WCB-Alberta, insurers or other authorized parties as permitted or required by law.
3. Products & Supplies
Products such as custom orthotics, compression stockings, braces and supports, pillows, and rehabilitation supplies may require
payment in full before they are ordered or provided.
Insurance coverage for products varies by plan. The patient is responsible for confirming coverage requirements with their insurer.
The clinic may assist with claim documentation but cannot guarantee reimbursement.
4. Cancellation, Missed Appointment & No-Show Policy
Your appointment time is reserved specifically for you. We request at least 24 hours' notice to cancel or reschedule an appointment.
Appointments cancelled with less than 24 hours' notice, missed appointments or no-shows may be subject to a cancellation/no-show
fee, up to the full scheduled appointment fee, except where waived by the clinic due to an emergency or exceptional circumstance.
Cancellation and no-show fees are generally not billable to insurance companies and remain the patient's responsibility.
The clinic may provide appointment reminders by phone, text or email as a courtesy. Reminders are not guaranteed, and patients
remain responsible for keeping track of their appointment times.
Repeated missed appointments may result in future appointments being limited, prepayment being required, or discharge from care
where clinically appropriate.
5. Late Arrivals
If you arrive late, your treatment session may be shortened to avoid delaying other patients. The treating provider will determine
whether enough time remains to safely and appropriately proceed with treatment.
The regular appointment fee may still apply even when the appointment is shortened because of late arrival.
6. Billing Information & Patient Responsibility
I understand that I am ultimately responsible for fees for physiotherapy, massage therapy, chiropractic services, acupuncture
services, products and other clinic services that are not paid by my insurance provider, WCB-Alberta, automobile insurer or other
approved third-party payer.
I agree to provide accurate and current information required for billing, including insurance details, policy or member numbers, WCB
or MVA claim information, and adjuster/contact information when applicable.
I understand that it is my responsibility to promptly notify the clinic of changes, expiry or termination of insurance or billing
information.
7. Outstanding & Past-Due Accounts
All outstanding balances are due and payable by the patient or financially responsible party.
If an account remains unpaid after reasonable attempts to obtain payment, The Bright Physio & Mindfulness Massage Inc. may take
lawful steps to recover the balance, including referral to a properly authorized collection service or other remedies permitted by law.
Personal and health information associated with an outstanding account will be handled in accordance with applicable Alberta
privacy requirements, and disclosures will be limited to information reasonably necessary and legally permitted for collection
purposes.
8. Consent for Personal & Health Information
The clinic collects personal and health information reasonably necessary to provide physiotherapy, massage therapy, chiropractic,
acupuncture and other healthcare services; maintain clinical records; arrange appointments; communicate with patients; process
payments; submit insurance claims; and operate the clinic.
Information may include contact information, date of birth, relevant health and medical information, referral information, insurance
and billing information, WCB or MVA claim information, and emergency contact information when provided.
Personal and health information will be collected, used, stored and disclosed in accordance with applicable Alberta privacy
legislation, including the Health Information Act where applicable. Reasonable safeguards are used to protect information against
unauthorized access, use or disclosure.
I understand that I may ask questions about how my information is handled and may request access to my records in accordance
with applicable law.
9. Communication & Release of Information
I understand that information reasonably necessary for my care, billing or claim may be communicated to authorized individuals or
organizations as permitted or required by law. These may include physicians, physiotherapists, chiropractors, acupuncturists and
other healthcare providers involved in my care, WCB-Alberta, automobile insurers, extended health insurers, case managers,
authorized adjudicators, lawyers or legal representatives when properly authorized, and other persons or organizations authorized by
me or permitted by law.
The clinic will limit disclosure to information reasonably necessary for the applicable purpose.
10. Clinic Communications
I consent to the clinic using the contact information I provide to communicate with me regarding appointments, reminders, invoices,
receipts, billing matters and information related to my care or visits.
I understand that electronic communication, including email and text messaging, may involve privacy risks, and I may request a
change to my preferred method of communication at any time.
11. Patient Acknowledgement
By signing below, I confirm that I have read and understand the clinic's payment and billing policies, cancellation/no-show and
late-arrival policies, and the clinic's practices regarding personal and health information.
I understand that direct billing does not guarantee insurance coverage or payment and that I am responsible for charges not paid by
my insurer or another third-party payer.
I understand that I may ask questions about fees, billing, privacy or clinic policies at any time and that I have had an opportunity to
ask questions before signing.