Order Number Your Information Your Name * Your Phone * Your Email * MVA Information Date of Accident * Claim Number * Insurance Company * Adjuster or Contact Name at Insurance Company * Adjuster's Phone * Adjuster's Email Direct Billing Authorization Since the motor vehicle accident, have your injuries been assessed? * Yes No Extended Health Care Benefits Do you have extended health care benefits? * Yes No Terms I affirm that the information provided is true and accurate. I am responsible to immediately update Muscle Matters of any and all changes to my insurance coverage, treatment plan, etc. I authorize Muscle Matters to direct bill my insurance company for my massage therapy treatments. I understand that I am responsible for paying for my treatment should coverage be denied by my insurance company. I agree that all MVA treatments that are direct billed to the insurer are billed according to the Advanced Therapy fee schedule to ensure the most suitable treatment for my injuries.