Dear Patient,

The Plumstead Wellness Centre provides services for the unfortunate event of an automobile accident or workman’s compensation injury. However, it is up to the treating doctor to determine if you have reached “maximum gains” under their care. If the doctor determines you are at maximal medical improvement, we do not expect a significant amount of additional improvement in your condition with further care that you would receive in our office. You will be released from care under your insurance case, although you may still have some residual symptoms.   

We do not make it a habit to exhaust a patient’s coverage, which is why we rarely treat a patient beyond 6 months from the time of the accident regardless of how much coverage remains on their plan. We are also required to forward all documentation to your insurance company. If they determine that your care is not related to your accident you will be responsible for your services here in the office.

I have read and understood all the above information.

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Patient Signature                                                              Date

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Witness