"*" indicates required fields Step 1 of 5 20% Your InformationYour Name* First Last Your Phone*Your Email* MVA InformationDate of Accident* Month Day Year Claim Number* Insurance Company* Adjuster or Contact Name at Insurance Company* Adjuster's Phone* Adjuster's Email Adjuster's Fax Direct Billing AuthorizationSince the motor vehicle accident, have your injuries been assessed?* Yes No 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 No Extended Health Care BenefitsDo you have extended health care benefits?* Yes No Insurance Company* Member ID* Policy Number* Your Date of Birth* Month Day Year 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* Month Day Year 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. CommentsThis field is for validation purposes and should be left unchanged. Δ
