DIRECT BILLING
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Therapist Selected
Please Select
Sasha Campbell
Tianna Steel
Katey Warrener
April LeBlanc
Provider:
*
Please Select
NONE
Blue Cross
Canadian Construction Workers Union
Chambers of Commerce Group Insurance
CINUP
Claim Source
ComPsych
Cowan
Desjardins Insurance
First Canadian
Canada Life
GreenShield
Group Health
Group Source
Industrial Alliance
Johnson Inc.
Johnston Group Inc.
LiUNA Local 183
LiUNA Local 506
Manion
Manulife
Maximum Benifit
Medavie / Veterans Affairs
Non-Insured Health Benefits (NIHB)
Sunlife
Telus Ajudicare
Other
Coverage Information:
Policy #
Member ID
Coverage Limit:
Name of Insurance Cardholder (if different from patient information):
First Name
Last Name
Parent
Child
Full-Time Student
Spouse
POSTAL CODE
*
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: