MVA Insurance Information - Muscle Matters

Step 1 of 5

Your Information

Your Name*

First Last

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

Adjuster's Fax

Direct Billing Authorization

Since the motor vehicle accident, have your injuries been assessed?*

Yes

Which health care provider provided the assessment?*

Medical Doctor

Physiotherapist

Chiropractor

Name of the facility that conducted the assessment*

Has the health care provider referred you for massage therapy?*

Yes

Extended Health Care Benefits

Do you have extended health care benefits?*

Yes

Insurance Company*

Member ID*

Policy Number*

Your Date of Birth*

Are you the primary insured member on this plan?*

Yes

Spouse of Primary Member

Child of Primary Member

Primary Member's Name*

Primary Member's Date of Birth*

Consent*

I agree to the MVA policy.

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.

This field is for validation purposes and should be left unchanged.