Luminous Nature Wellness Spa -----intake form

Luminous Nature Wellness Spa -----intake form
Name

First NameLast Name

Please fill out the following if you would like us to direct bill your insurance provider

Luminous Nature Wellness Spa
Benefit assignment form
I hereby assign benefits payable for the eligible claims to the healthcare provider responsible for submitting my claims electronically to
the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to such provider. In the event my claim(s)
are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the healthcare provider for any services rendered and/ or supplies provided.
I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this benefit assignment form, that any
benefit payment made in accordance with this benefit assignment form will discharge the insurer/plan administrator of its obligations
with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be
discharged of its obligation with respect to that benefit payment.
I understand that this assignment will apply to all eligible claims submitted electronically by my healthcare provider and that I may revoke
it at any time by providing written notice to the insurer/plan administrator.
If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the
healthcare provider.
I give consent to bill my insurer or plan administrator and collect funds for the services received from provider. As well as consent to collect and exchange personal information with insurer.--initial below
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I understand that any information we collected and disclose about you, and if applicable your spouse or dependents is used by the insurer and or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administrating the group benefits plan, including investigating fraud and / or plan abuse.-----initial below
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I authorize my healthcare provider / Motayo Dawodu of Luminous Nature Wellness Spa, to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and or plan administrator and their service provider(s) for the above purposes.----initial below
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I understand that personal information may be subject to disclosure to those authorized under applicable law.----initial below
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I agree to reassign funds to Motayo Dawodu / Luminous Nature in the case I should receive funds for services provided.---initial below
I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.----initial below
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I confirm that I am authorized by my spouse and / or dependents, if any, to disclose personal information about them to the insurer and or administrator and their service provider(s) for the purpose of assessing and paying a benefit.----initial below
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Yes I give my signature for accepting the terms stated above

Clear
Name & Date:
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All information contained herein is protected by privacy laws including the Personal Information Protection and Electronic Documents
Act (PIPEDA) and all the corresponding provincial legislation. All users agree to protect the personal health information contained herein
from unauthorized use, disclosure, loss, theft, or compromise in accordance with the above noted laws and with at least the same care
employed to protect their own confidential information. Any unauthorized access, disclosure or use of this information is illegal.
Plan Members Name

First NameLast Name
Plan Members DOB

MonthDayYear
Date
Spouse or Dependent Member

First NameLast Name
Spouse or Dependent Member DOB

MonthDayYear
Date
Insurance Provider
Percentage covered?
Group # ID # other:
Should be Empty:

Luminous Nature Wellness Spa -----intake form

Please fill out the following if you would like us to direct bill your insurance provider