Direct Billing for Extended Health Care "*" indicates required fields Step 1 of 3 33% Insurance InformationInsurance Company*Select your insurerAlberta Blue CrossAlberta School Employment Benefit Plan (ASEBP)Beneva Inc.BPA - Benefit Plan AdministratorsCanada Life (formerly Great West Life)Canadian Construction Workers UnionChambers of Commerce Group InsuranceCINUPClaimSecureCoughlin & Associates Ltd.CowanD.A. TownleyDesjardins InsuranceEmpire LifeEquitable Life of CanadaFirst CanadianGMS Carrier 49GMS Carrier 50Greenshield Canada (ARTA - Alberta Retired Teachers Association)GroupHEALTHGroupSourceIndustrial AllianceJohnson Inc.Johnston Group Inc.La Capitale/ BenevaLiUna Local 183LiUna Local 506ManionManulifeMaximum BenefitMedic ConstructionPeople CorporationRWAM Insurance AdministratorsSSQ InsuranceSunlifeTELUS AdjudiCareUnion BenefitsUV InsurancePolicy NumberMay also be called Group NumberMember ID Client InformationYour Name* First Last Email* Date of Birth* Month Day Year Are you the primary insured member on this plan?* Yes No Primary Insured Member's Name*Primary Insured Member's Date of Birth* Month Day Year What is your relationship to the primary insured member? Spouse Domestic partner Child Full-time student Part-time student Insurance Card*Send us a photo or scan of your insurance card. Make sure all details are clearly visible. JPG or PDFs only. Max file size 10 MB.Accepted file types: jpg, pdf, Max. file size: 10 MB.Authorization*I authorize Muscle Matters to direct bill my insurance company for my massage therapy treatments. I also understand that if for any reason my insurance company refuses payment, I am required to pay for these treatments. I recognize that the clinic’s cancellation policy will not be waived due to insufficient benefits. I agree to the direct billing policy.NameThis field is for validation purposes and should be left unchanged. Δ
