FORM 4C

PATIENT TYPE FOUR (4)

ACTIVE THERAPY WITH SEXY BACK IN-PERSON OR ONLINE CLASSES

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IMPORTANT

YOUR INFORMED CONSENT MUST BE WITNESSED

 

THE INFORMED CONSENT & INJURY RELEASE

ACTIVE THERAPY PROGRAM WITH SEXY BACK INSTRUCTOR

PLEASE READ:

 

 

PATIENT TYPE FOUR

THE SEXY BACK GROUP THERAPY CLASSES.

You are a patient Better Call Doc. Please fill-in the medical history (FORM 1A). If you have limitations, a medical condition, injury, impairment or disability Dr Rice may require a tele-medicine or in-person consultation & examination.

You wish to participate in-person or online with a 30 minute Sexy Back class.

You have purchased the medical self-help book entired 'Sexy Back' & wish to learn and participate in classes for the purpose of:

Helping your chronic back pain

Improving your core musculature & strength,

Improving your posture

Maintaining you back mobility, strength & flexibility

And finally,

Empowering your physique to look sexy, feel sexy & be sexy.

INTENTION OF THIS INFORMED CONSENT

We request your understanding in maintaining both your and our safety by reading and signing the following INFORMED CONSENT AGREEMENT & INJURY RELEASE.

 

I, as the patient, am aware that all activities, treatments, services and programs offered are either therapeutic, educational, recreational, or self-directed in nature.

 

I assume full responsibility during and after my group class participation as my choices to use or apply, at my own risk, any portion of the information or instruction I receive from a BCD INC (Better Call Doc INC) or Brave Health practitioner or associate or Sexy Back trainer. I understand that sexy Back is a subsidiary division of Better Call Doc Inc. & is offered as a separate membership & treatment program.

 

BCD INC BRAVE HEALTH ACTIVE THERAPY PRACTITIONERS & SEXY BACK TRAINERS

Must be licensed and independently insured professionals with one of the following degrees: kinesiology, fitness trainer, Bachelor of Physical Education. Must be trained and certified by the BCD INC/Brave Health SYSTEM OF PATIENT CARE AND MANAGEMENT prior to commencing direct unsupervised Brave Health Active Therapy treatments.

 

BCD INC AND BRAVE HEALTH CERTIFICATION OF PRACTITIONERS

I understand that Brave Health active therapy practitioners are certified by work with the BCD INC and its chief primary care physician, Dr. Michel Rice. I also understand that all treatments involve safe therapeutic modalities (pain management and exercise) that can be used by myself at home. BCD INC and Brave Health programs principally involve responsibilities of guidance, adherence to pain management, monitoring of dosage of care, adherence to active rehabilitation participation rates and feedback monitoring systems that may also work in collaboration with my primary care physician. I understand that fitness practitioners are independently licensed with malpractice insurance that also covers my active training sessions..

OCA RECOMMENDED BILLING FEES FOR ACTIVE THERAPY

The Ontario Chiropractic Association recommends three service codes that are routinely used in the SEXY BACK online or in person program:

2501 Exercise Brief instruction for self-directed exercise $28 less than 10 minutes

2502 Exercise / Functional Restoration: In office (clinic / wellness facility) constant supervised (one-one-one) $68 per 20 minutes

2503 Exercise / Functional Restoration: In office (clinic / wellness facility) supervision or group $56 per 30 minutes

HEALTH PLAN BILLING

I understand that my health plan may be used to cover the cost of my active therapy. The conditions for billing involves but is not limited to the above outlined OCA code classes. The billing structure must be authorized by both Dr. Rice and the Fitness Practitioner prior to commencing therapy. I understand that plans vary extensively in the Province of Ontario. I agree to outlay the billing and payment structure prior to commencing my rehabilitation. I am fully responsible to report my personal coverage and will remain responsible for any shortfall between what the insurance will cover and what I have agreed to pay on a per visit basis. I also understand & agree on thee monthly billing structure for single-session/therapy fees. I am to pay & BCD will provide a paid receipt for my submission to the insurer.

Again, I understand that direct insurance billing is not accepted by Better Call Doc INC/ After completion of each month's active therapy sessions, BCD Inc. will provide me with a paid receipt (via credit card) after which I am to submit to my insurer my receipt for receipt of the payment, in part or in total, depending on my individual private health insurance plan. If I require a detailed receipt I understand that an administrative fee of $20 applies each month.

 

I understand that some session dates involve stand-alone rehabilitation sessions that remain under the supervision of the fitness practitioner (Code 2503).

HEALTH POLICY FINANCIAL TERMS

CREDIT CARD MONTHLY AUTHORIZATION POLICY

I authorize Better Call Doc INC to process my credit card on a monthly basis.

I understand that BCD INC re-evaluations for any of my injuries or impairments have additional examination fees which are $62 per re-evaluations. The re-evaluations are conducted by Dr. Rice and can be conducted in person or via tele-medicine consults.

 

FINAL ACKNOWLEDGMENT AND CONSENT

I hereby and hold harmless Dr. Michel Rice, Chief of BCD INC, Sexy Back Program as a subsidiary program of Better Call Doc Inc., the Sexy Back fitness practitioner & Better Call Doc Incorporated, it’s agents, officers, health practitioners, fitness practitioners and employees and any affiliated companies from any liability with respect to any causes of action, claims, damages, loss or injury of any nature to me or my property arising out of, or connected with my exercise participation or therapeutic involvement with Better Call Doc INC associates.

 

I acknowledge that I have read this consent and I have discussed or have been offered the opportunity to discuss, with Dr. Rice or his associates, the nature and purpose of chiropractic treatment in general. The treatment options and recommendations for my condition, and the contents of this Consent.

 

I intend this consent to apply to all my present and future BCD INC care practitioner treatments and/or Brave Health Active Fitness Practitioner treatments.

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PAR Q Physical Activity Readiness Questionnaire

I declare that I have read, understood and agree to the contents of this INFORMED CONSENT AGREEMENT in its entirety.

The consent has been explained by the doctor or Active Therapy Trainer/Practitioner before I have consented to treatment.

Consent to treat a minor (less than 16 years old)

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