DATEOur File:<
Please quote our file numberin all correspondence
<
<
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<
<
ATTENTION: <
RE:<
We have set aside an appointment for which we respectfully request the above-named to be available:
<
<
<
DATE:<
TIME:<
Theresa E.
Intake Nurse INTAKE CALL #:<
DATE:Date
TIME: Time
<
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 the Terms and Conditions Form. The deadline for this is <
<
As with all appointments made with professionals it is very important to arrive as scheduled. If <
All medical documentation is to be sent to Western Medical Assessments 60 days before the appointment for Ms. Wilson to review, which in this case is <
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, Dr 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 & Conditions Form
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 Mr Betty Wilson as necessitated by the matter involving <
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 Ms. Betty Wilson is performing an independent
assessment of me at the request of
<
(the “requesting party”) as arranged through
Western Medical Assessments.
I have been informed that Ms. Wilson is not employed by the requesting party. Ms. Wilson has been asked to give an independent report on my condition following history taking, examination and obtaining any tests or investigations they deem necessary.
I hereby release Ms. Wilson 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 Ms. Wilson 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: _____________________________________________
Ms. Betty Wilson
Occupational Therapist
WESTERN MEDICAL ASSESSMENTS TERMS AND CONDITIONS
Cancellations will be accepted until 12:00 noon, 60 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 Claimant cancels or fails to attend as scheduled, the ‘noshow’/late cancellation fee plus any additional fee the examiner feels necessary for review of documentation will apply.
We enclose an “Agreement to Pay Fees” form that we would ask you to read and sign where indicated, and return to us along with the deposit no later than the cancellation deadline date provided on the Appointment Confirmation Letter.
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. This 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 her/his 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 purposes or written purposes, please advise us immediately. Please also advise as to the preferred language of communication, so the appropriate arrangements can be made. 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 Certified Examination Doctors have a professional duty to take whatever amount of time is necessary to review documentation. They will not limit themselves to 5.5 hours per the Minor Injury Regulations and will charge for compensation of time spent. If your principal is not willing to pay any more than what is stated in the Minor Injury Regulations, we ask you to provide only the documents directly related to the motor vehicle accident in question, such as emergency room and/or paramedic services records. Should Doctors find that this does not suffice to establish whether the injury sustained is or is not a minor injury, they will ask to have you produce additional material. Any time spent above the 5.5 capped hours that the Doctor may require to complete the report/s, are billable as per the Doctor’s hourly rate. In consideration of this, and to avoid incurring additional hourly rates set by the Doctor, no documentation whatsoever, other than emergency room and/or paramedic services records, will be reviewed ahead of the assessment in order to avoid the risk of Doctors having to spend more than 5.5 hours to fulfill their ethical obligations. Per the regulations, should Doctors require any documentation, they will ask for same. You are asked to not send any documentation other than what is noted above.
All medical documentation is to be forwarded to our office at least 60 days prior to the appointment to avoid cancellation of appointment for which you would be financially liable.
If VIDEOTAPE/VIDEOGRAPHY has been approved, it will only be acceptable for a professional videographer to be in attendance. 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.
If there is any enclosed checklist and/or questionnaire from the examiner, please have the Claimant fill these out with as much detail as possible prior to their assessment. They are then to bring the completed checklist/questionnaire along to the 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.
Have Claimant bring shorts and a T-shirt to change into if they would prefer comfort while being examined.
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, limit the number of support people accompanying Claimant to appointment to one.
The following1-4 (including XII above) are instructions for a respiratory appointment:
Avoid taking any short acting bronchodilators for 4 hours prior to the appointment (e.g. Ventolin, Bricanyl, and Atrovent);
Avoid taking any long-acting bronchodilators for 12 hours prior to this appointment (e.g. Oxeze, Serevent, Symbicort, Advair and Spiriva);
If your Claimant is a smoker, please have them refrain from smoking three hours prior to the appointment;
Due to our patients’ respiratory conditions, we ask anyone coming in this clinic, including those accompanying the patient, to refrain from wearing scented products.
__________________________________________ _____________________________________________
SIGNATUREDATE