At Kinetic Physiotherapy & Massage in Maple Ridge, our Treatment Philosophy emphasizes quality care with your Physiotherapist….

(604) 467-2113
info@kineticphysio.ca
12005 238B Street, Suite #103
Maple Ridge BC, V4R 1W1

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Direct Billing & Patient Information

Appointment Information

Booking appointments:

At Kinetic Physiotherapy, appointments are typically 60 minutes long. We are a very busy clinic and typically have a waitlist of patients. Because of this, we recommend when booking a new appointment, that you also book 1-2 follow up appointments as well. If your follow-up appointment(s) are not needed, we will gladly cancel them for you.

We offer two convenient ways to schedule an appointment with our Physiotherapists & Registered Massage Therapists

  1. In Person at Kinetic Physiotherapy & Massage in Maple Ridge / Over the Phone:
  • Just give us a call at (604) 467-2113, we would love to hear from you!
  • If you happen to reach our voicemail, we will typically be able to return your calls within 24 hours of your call.

2. Online through our convenient appointment scheduler:

  • Just click the link below which will direct you to our online appointment scheduler. You will be provided with instructions on how to set up an account and then be able to manage your appointments any time of day!

ICBC/Worksafe BC:

  • Please note that we no longer bill to Worksafe BC for treatment. If you are a Worksafe BC patient and wish to attend our clinic, you must have permission from your case manager for treatment to be directly billed to work safe at our private rates.
  • ICBC patients are typically able to initiate Physiotherapy treatment without a doctor referral. ICBC may request a doctor referral at some point during your treatment in order to receive ongoing treatment coverage.
  • Please contact the clinic if you have any questions about ICBC and/or Worksafe BC claims. We would love to hear from you!

What to wear

– Please wear comfortable or loose fitting clothing that will allow our therapists to assess your movement easily. For lower body injuries, please feel free to bring shorts and comfortable shoes with you for your appointment.

What to bring

– Please feel free to bring in any information regarding your condition to your appointment (i.e. Imaging reports, doctor referrals, Medication lists, etc).

Cancellation Policy

– We reserve your appointment slot just for you! Please provide 24 hours notice of any appointment cancellation. Cancellations less than 24 hours may be charged a cancellation fee.

Direct Billing

Companies we are able to directly bill to:

  • CINUP
  • Chamber of Commerce Group Insurance
  • Cowan
  • Desjardins Insurance
  • First Canadian
  • Great-West Life
  • Group Health
  • Group Source
  • Industrial Alliance
  • Johnson Inc.
  • Johnson Group Inc.
  • Manion
  • Manulife Financial
  • Maximum Benefit
  • Sunlife
  • Pacific Blue Cross

Information For Direct Billing

For direct billing to Blue Cross

  • You must bring in your Blue Cross Benefits card to the clinic on your first appointment.
  • A copy of the card will be taken and stored on your file
  • If you are unable to provide your Blue Cross Card, we will not be able to directly bill for your appointment on that day. You will be issued a receipt for your treatment for which you would be able to submit to Blue Cross manually.

 

For direct billing to all other insurance companies (see list above):

  • Please fill out the Assignment and E-Claim form (see link below)
  • Please note that if the associated forms have not been completed prior to your appointment, we will not be able to directly bill for your appointment on that day.
  • You will be issued a receipt for your treatment for which you would be able to submit to your insurance company manually.

Personal Health Information Consent Form


I authorize Kinetic Physiotherapy to share my personal information with any other healthcare professionals involved in my care. Kinetic Physiotherapy cares about your privacy and will only share information in order to facilitate best treatment.

I authorize Kinetic Physiotherapy to contact the imaging department of my hospital, my Family Physician’s office or private imaging company in order to request copies of reports related to my injury or impairment. Requested reports may include but are not limited to X-ray, MRI, CT scan, and ultrasound.

I authorize Kinetic Physiotherapy to contact any insuring agency involved in my claim. Examples of insuring agencies include, but are not limited to, ICBC, WorkSafeBC, and Blue Cross.

I authorize Kinetic Physiotherapy to share my medical information with my Lawyer or Representative (Name :). This might include communicating via telephone and/or sending copies of Physiotherapy Assessment and Treatment notes obtained during treatment at Kinetic Physiotherapy.

The purpose of any of the above contact will be to facilitate effective assessment, treatment, or other services for me. Contact with any of the above may occur via mail, email, fax, or voice.
By signing below I am indicating that I have read, understood, and consent to the above initialed sharing of information. I understand that I can withdraw consent for Kinetic Physiotherapy to contact any of the above organizations at any time by providing this instruction in writing.




Assignment & E-Claim Form

Instructions: This form must be filled out when claim payment is assigned to the Provider. Please retain this form in the patient’s file for verification purposes for two years following closure of the patient file.

Patient:














Provider










I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/ or supplies provided.
I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.
I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator.
If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.

Consent to Collect and Exchange Personal Information


Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and / or plan abuse.

I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes.
I authorize the insurer and / or plan administrator and their service provider(s) to:

  • use my personal information for the above purposes.
  • exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.
  • exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.
  • exchange personal information for the above purposes electronically or in any other manner.

I understand that personal information may be subject to disclosure to those authorized under applicable law.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.


I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose.




Personal Health Information Consent Form


I authorize Kinetic Physiotherapy to share my personal information with any other healthcare professionals involved in my care. Kinetic Physiotherapy cares about your privacy and will only share information in order to facilitate best treatment.

I authorize Kinetic Physiotherapy to contact the imaging department of my hospital, my Family Physician’s office or private imaging company in order to request copies of reports related to my injury or impairment. Requested reports may include but are not limited to X-ray, MRI, CT scan, and ultrasound.

I authorize Kinetic Physiotherapy to contact any insuring agency involved in my claim. Examples of insuring agencies include, but are not limited to, ICBC, WorkSafeBC, and Blue Cross.

I authorize Kinetic Physiotherapy to share my medical information with my Lawyer or Representative (Name :). This might include communicating via telephone and/or sending copies of Physiotherapy Assessment and Treatment notes obtained during treatment at Kinetic Physiotherapy.

The purpose of any of the above contact will be to facilitate effective assessment, treatment, or other services for me. Contact with any of the above may occur via mail, email, fax, or voice.
By signing below I am indicating that I have read, understood, and consent to the above initialed sharing of information. I understand that I can withdraw consent for Kinetic Physiotherapy to contact any of the above organizations at any time by providing this instruction in writing.




Assignment & E-Claim Form

Instructions: This form must be filled out when claim payment is assigned to the Provider. Please retain this form in the patient’s file for verification purposes for two years following closure of the patient file.

Patient:














Provider










I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/ or supplies provided.
I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.
I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator.
If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.

Consent to Collect and Exchange Personal Information


Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and / or plan abuse.

I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes.
I authorize the insurer and / or plan administrator and their service provider(s) to:

  • use my personal information for the above purposes.
  • exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.
  • exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.
  • exchange personal information for the above purposes electronically or in any other manner.

I understand that personal information may be subject to disclosure to those authorized under applicable law.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.


I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose.