Direct Billing Form

 
 

We are now set up for direct billing for massage therapy treatments to most insurance companies.  This means if you have insurance coverage we can bill your insurance company directly for payment, and you only have to pay the small portion that is not covered!  Less out of pocket money for massage therapy treatments is awesome!!

PLEASE NOTE:  Everyone’s insurance policy is different.  In some cases, your provider does not pay the clinic directly.  In this case, we can process your claim for you, but you will be asked to pay for your treatment in full. You will then receive re-embursement directly from your insurance company.  

Credit Card

There are also other situations where your insurance company may not cover as much of your treatment as you thought. Unfortunately some insurance companies only tell us several days after your treatment how much they are going to cover.  This is why we ask to keep a credit card on file, so we can charge any outstanding balance that your insurance company didnt pay.  We will NEVER charge your card without contacting you first and sending you written proof that there is an outstanding balance due.

We will collect your credit card number at your next visit to MyoCare

 

We can now direct bill for the following insurance companies:

  • Sunlife Financial
  • Desjardins Insurance ( Does not pay clinic directly, you will be asked to pay for the treatment in full, and get re-embursed directly from your insurance company)
  • Chamber of Commerce Group Insurance PLan
  • Cowan
  • iA Financial Group
  • Manulife  ( you must sign up for direct billing on the manuLife website before we can direct bill with Manulife Life)
  • Maximum Benefit
  • Johnson
  • Johnston Group
  • Great West Life  
  • CINUP
  • First Canadian

There is some paper work to fill out before we can set you up, so if you are interested please fill in the following form and submit it to us.

 

Name *
Name
Date of birth *
Date of birth
Is this your personal insurance or your partners *
Policy holders Date or birth ( if not your own policy)
Policy holders Date or birth ( if not your own policy)
Consents
Consent to collect and exchange personal information.. *
essage to the Plan member, Spouse and/or Dependent regarding 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.
Authorization and consent *
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.
Electronic Transmission Authorization and Consent Form *
Additional Consent Applicable to Plan Members Only 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.
*
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.