Goodwin Massage Therapy Clinic
Direct Billing Request Form
This form provides your massage therapist with the information necessary to bill your benefits company
directly for treatments provided at Goodwin Massage Therapy Clinic. All information collected for
these purposes will not be shared unless it is required by law or with written consent from you. You may
be required to pay a percentage of the cost of your treatment or have a prescription from your doctor,
depending on your plan. You have the right to change your billing options at any time and are under no
obligation to have Christina bill directly for you. Please note that this option is only available to the limit
of your massage therapy benefits, after which time you will be required to cover the cost of your
treatments.
I understand the above information and consent to Christina Goodwin RMT of Goodwin Massage
Therapy Clinic to bill my insurance company on my behalf for my treatments.
Print name:________________________________________________
Signature:__________________________________________________Date:____________________
Insurance Company:
o
o
o
o
o
o
o
o
o
o
Sunlife Group Benefits
Great west life
Desjardins
Green Shield (most plans won’t pay to service provider)
Johnson Inc
Standard Life Assurance
Industrial Alliance
Chamber of Commerce Group Insurance Plan
Maximum Benefit or Johnson Group
Manulife (you must register online for me to bill for this company)
Name of Policy Holder:________________________________________
Birthdate of Policy holder:_______________
Is the policy holder your spouse? Y
N
(m-d-y)
Policy Number:__________________________________________
Is a doctor’s note required for your massage treatment? (if known)
Member ID:________________
Y
N
First and Last Name of your Doctor________________________________________________________
Amount of yearly coverage (if known)___________________
Goodwin Massage Therapy Clinic