DATEOur File:< >

Please quote our file numberin all correspondence

< > < >

< >

< >

< >, < >Scanned and e-mailed to:

< >< >

ATTENTION: < > < >:

RE:< >, < > Your File Number: < >

We have set aside an appointment for which we respectfully request the above-named to be available:

< > < > < >LOCATION:< >

< >< >

< >, < >

DATE:< >

TIME:< >

Theresa E.

Intake Nurse INTAKE CALL #:< >

DATE:Date

TIME: Time

< > < > <CMLast>>’s availability for this appointment has been confirmed. The cancellation deadline is < >.

Or

It is too late to change or cancel this appointment.

As a matter of company policy, we respectfully request the signed attached documents: the Agreement to Pay Form, and Evaluation Terms and Conditions. The deadline for this is < >.

< > < > will be given a release form to sign before being examined. Enclosed is a copy for your review. Please note, we are not asking for it to be signed before the appointment. It is presented here so that < > < > may be aware of the form and prepared to sign it at the time of the evaluation.

As with all appointments made with professionals it is very important to arrive as scheduled. If < > < > arrives late, Dr. Oskin may not be able to conduct the interview and evaluation due to other commitments, in which case the appointment will be treated as a no-show/late cancellation incurring a charge of $< > plus the GST. Please factor in appropriate amount of time to travel to his office and to park.

All medical documentation is to be sent to Western Medical Assessments within 24 hours of the appointment being confirmed for Dr. Oskin to review, which in this case is < >. Please be advised to include your waybill if you require the documentation to be returned. If a return waybill is not provided, the documentation will be destroyed 30 days after the assessment.

If you have questions regarding any aspect of the above, please contact me at 1.800.290.2189 or communicate with me at appt.coord@westernmedical.ca. Any and all medical questions should be addressed to our Medical Director, Mr. Roger Hodkinson, at the same telephone number.

Thank you for the opportunity of being of service.

Sincerely yours,

Western Medical Assessments Corporation

Nicole Boon

Appointment Coordinator

attachs:Agreement to Pay Form/Release Form/Terms and Conditions

Agreement to Pay Fees Within 30 Days

RE: < >, < >

My signature below will serve as my agreement to pay fees charged by Western Medical Assessments Corporation for services rendered, and to make payment for same within 30 days of the date of the invoice.

Fees that may be charged are in respect of services we will request of < > < > < > as necessitated by the matter involving < > < > < > and/or HIS/HER solicitor and include IMEs, document reviews as well as, but not limited to, the signing of an Expert Witness Statement per the Alberta Rules of Court, Court preparation and testimony, no-shows/late cancellations, administrative, clerical and professional services, disbursements, etc. I have read the Terms and Conditions and Fee Schedule document, created in September 2003, revised and updated periodically since that time, and agree to abide by the conditions stated therein.

I understand Western Medical Assessments Corporation is obliged by the CCRA to apply the Goods and Services Tax to the services it renders and is obligated by the Federal Government to request and receive this tax from all clients except provincial ones.

< >

______________________________________________________________________________

SignatureCompany Name

________________________________

Date

AUTHORIZATION TO RELEASE INFORMATION

I recognize that < > < > < >

is performing an < > of me

at the request of

< >

(the “requesting party”) as arranged through

Western Medical Assessments.

I have been informed that < > < > is not employed by the requesting party. < > < > has been asked to give an independent report on my condition following history taking, evaluation and obtaining any tests or investigations he deems necessary.

I hereby release < > < > to disclose any findings to the requesting party. I understand that only the requesting party can release a copy of the report to me.

I acknowledge that < > < > is not my physician; I have not been under their care and am not their patient.

Signature: _____________________________________________

Full Name (please print): _________________________________

Date: _________________________________________________

Time In: ______________________________________________

Time Out: _____________________________________________

< > < > < >

< >

WESTERN MEDICAL ASSESSMENTS

EVALUATION TERMS AND CONDITIONS

Cancellations will be accepted until 12:00 noon, 21 days prior to appointment without incurring late cancellation fees. Should you cancel after that time, or should the Claimant not attend appointment/s, there will be a ‘no-show’ fee as per the Appointment Confirmation Letter (plus any additional fee the examiner feels necessary for review of documentation).

Arrival on schedule is required for all appointments with examiners. If the Claimant arrives late, examiners may not be able to conduct the interview and examination due to other commitments, in which case the appointment will be treated as a ‘no-show’/late cancellation incurring a fee plus any fee the specialist feels is adequate to compensate him for review of documentation. Claimants should allow plenty of time for parking.

In the unlikely event that the Claimant cancels or fails to attend as scheduled after the confirmation deadline date, your company will be invoiced for a ‘no-show’/late cancellation fee plus any additional fee the examiner feels necessary for review of documentation. If an appointment is made within the three-week confirmation deadline date and the client cancels or the claimant fails to attend as scheduled, the ‘noshow’/late cancellation fee plus any additional fee the examiner feels necessary for review of documentation will apply.

As a matter of company policy, we may respectfully request a retainer/deposit as well as the signed attached documents: the Agreement to Pay form, the Release Form, and the Terms and Conditions Form. Any retainer/deposit will be refunded to the payer, minus an administrative fee, should the need for an assessment fall through and the cancellation deadline has been met.

Claimant will be asked to fill out a Release Form for the appointment/s. A sample is attached. Please note, we are not asking for you to have this signed now, but are presenting it so that the Claimant will be advised and prepared to sign it at the time of the appointment/s.

If the Claimant is not fluent in English for either oral or written purposes, please advise us immediately.  Please also advise as to the preferred language of communication so an interpreter can be made available.  Should the examiner not be able to conduct the interview and examination due to a language barrier, the ‘no-show’/late cancellation fee plus any additional fee the examiner feels necessary for review of documentation will apply.

All medical documentation is to be forwarded to our office immediately upon confirmation of the appointment to avoid cancellation of the appointment for which you would be financially liable.

If VIDEOTAPE/VIDEOGRAPHY has been approved, it will only be acceptable for this to be performed by a professional videographer.  Following are conditions for same:

The filming must not commence until Claimant enters the actual examining room so as to prevent the inclusion of any other patient in the filming;

If the videographing in any way inconveniences the examiner, the assessment and evaluation will be halted at a cost to your client;

Examiners require a copy of the video within 10 working days of the assessment; and,

Examiners require a commitment from opposing counsel that the video will be viewed only by counsel and by other examiners involved.

PLEASE NOTE THAT SOME EXAMINERS DO NOT ALLOW VIDEOTAPING OR A NOMINEE UNDER ANY CIRCUMSTANCES, REGARDLESS OF THE RULES OF COURT. PLEASE INSURE THAT YOU INQUIRE ABOUT THIS POSSIBILITY PRIOR TO CONFIRMING APPOINTMENT.

The following are instructions for your appointment:

If the plaintiff wears eyeglasses or corrective eyewear, it is essential that he/she brings these along to the appointment.

We provide shorts and t-shirts for all examinations however the claimant is welcome to provide their own for comfort.

Claimant should provide a list of their current medications along with their Provincial Health Card and photo identification (e.g. driver’s license).

Due to limited space in our waiting room, please limit the number of support people accompanying Claimant to appointment to one person.

___________________________________________________

SIGNATUREDATE