DO NOT FILL-IN UNLESS YOU ARE IN THE CLINIC OR FITNESS FACILITY
& THE INFORMED CONSENT HAS BEEN EXPLAINED
WITH THE DOCTOR OR ACTIVE THERAPY TRAINER/PRACTITIONER
THE INFORMED CONSENT & INJURY RELEASE
ACTIVE THERAPY PROGRAM WITH FITNESS PRACTITIONER
PATIENT TYPE THREE
THE BRAVE HEALTH PATIENT (A SUB-PROGRAM TO BETTER CALL DOC INC (BCD INC))
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 treatment participation for 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.
BCD INC BRAVE HEALTH ACTIVE THERAPY PRACTITIONERS
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 BCD INC and Brave Health practitioners are certified by the BCD INC 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 independantly 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 Brave Health 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 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 understand that I must sign off on each session billable for any rehabilitation treatment session (Signing of attendance sheet and/or each individual program). Brave Health will not invoice my insurance if I have not signed off on each session.
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 $80 per examination. The examinations 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 and Brave Health Clinical Operations 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.