Direct Billing Information & Consent
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Insurance
I have insurance
Insurer
Blue Cross
BPA - Benefit Plan Administrators
Canada Life
Canadian Construction Workers Union
Chamber of Commerce
CINUP
ClaimSecure
Cowan
D.A. Townley
Desjardins Insurance
Empire Life
Equitable Life
First Canadian
Green Shield Canada
Group Medical Services Carrier 49
Group Medical Services Carrier 50
GroupHEALTH
GroupSource
Industrial Alliance
Johnson Inc.
Johnston Group Inc.
La Capitale Insurance and Financial Services
LiUNA Local 183
LiUNA Local 506
Manion
Manulife
Maximum Benefit
Other
People Corporation
RWAM
SSQ Insurance
Sun Life
TELUS AdjudiCare
Union Benefits
Policy Name
Policy / Group / Plan #
Member ID / Certificate #
Policy Holder
I'm not the policy holder.
First Name
Last Name
Relationship To Patient
Child
Parent
Spouse
Common Law Spouse
Other
Date of Birth
Address
City
Prov / State
Postal / Zip Code
Phone Number
Prescriber
First Name
Last Name
Other
Additional Insurance Information:
If you have a prescription from your Doctor, what is the date of the prescription? (*Please note* Prescription must be brought to your appointment to be used)
Characters:
0
/255
If you are not the policy holder for the above insurance, please provide the policy holder's date of birth:
Characters:
0
/255
Secondary Insurance
Insurer
Characters:
0
/255
Policy/Group Number
Characters:
0
/255
Member ID/Certificate Number
Characters:
0
/255
Policy Holder's First and Last name
Characters:
0
/255
Policy Holder's Date of Birth
Characters:
0
/255
Relationship to Policy Holder
Child
Insured Member
Parent
Spouse / Common Law Spouse
Other
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Direct Billing Policy, Assignment of Benefits Authorization & Consent Form
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