Order Number Client Information Full Name * Your Email * Date of Birth * Are you the primary insured member on this plan? * Yes No Insurance Company Insurance Company * BPA Canada Life Canadian Construction Workers Union Chamber of Commerce Group Insurance CINUP ClaimSecure Cowan D.A. Townley Desjardins Insurance First Canadian GMS Carrier 49 GMS Carrier 50 GroupHEALTH GroupSource Industrial Alliance Johnson Inc. Johnston Group Inc. LiUNA Local 183 LiUNA Local 506 Manion Manulife Financial Maximum Benefit People Corporation RWAM Insurance Administrators Sun Life Financial Telus AdjudiCare Union Benefits Policy Number * Member ID * Treatment for Accident Are we treating injuries caused by an accident? * Yes No Prescription Do you have a physician's prescription/referral for massage therapy? * Yes No 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. Authorization 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.
