Direct billing

Client Name:*
DOB*
YYYY slash MM slash DD
Relationship*
Insured Member’s Full Name
DOB
YYYY slash MM slash DD
Policy #
ID or Member#
Type of insurance*
Name of Insurance*
Untitled*
- I agree that I am registered under this plan and have permission to direct bill my insurance company for Massage Therapy, Physiotherapy Chiropractic or Naturopathic treatments.
Untitled*
- I agree to the assignments of benefits for services that I may receive from Lavallee Health Centre. They may bill directly to my insurance provider and have the payment go directly to the Lavallee Health Centre. If my treatments are only partially covered by my plan, I agree that I am fully responsible for the balance and will make payment immediately to settle the outstanding balance.
Untitled*
- I understand that in the event that legal action is necessary to collect any accounts in arrears, that only the necessary information will be released to the courts.
Signature*
Date*
YYYY slash MM slash DD

Space is Limited. Call us for more information.