Insurance Policy & Payment Agreement

Required Field

Personal Info

First Name

Last Name

Policy Name : Anything you'd like to name this policy (i.e Work, Spouse, Employer Name)

If you are unsure as to what your Policy / Group / Plan # & Member ID / Certificate # are, feel free to send a snapshot of your card to 780-871-1202 or add all the details on the card in the "More information" section of this form.

INSURANCE INFORMATION:

Insurance

I have insurance

Insurer

Policy Name

Policy / Group / Plan #

Member ID / Certificate #

Policy Holder

I'm not the policy holder.

First Name

Last Name

Relationship To Patient

Date of Birth

Address

City

Prov / State

Postal / Zip Code

Phone Number

More Information:

Additional information if required

Review & Agree

Insurance Payment Authorization (Review Required)

You need to review and accept this before submitting

Signature