"*" 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. 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.NameThis field is for validation purposes and should be left unchanged. Δ
