Health Insurance Provider Information

If you are accessing pelvic health physiotherapy via an approved insurance provider and require Steph Lyons Physio to invoice your insurer directly, please complete the form below to confirm your appointment(s).

Steph Lyons Physio is registered with selected insurance providers for direct invoicing. If your provider is not listed within this form, your appointment will be charged at the self-pay rate. You may wish to check with your insurer whether you can claim reimbursement directly.

Pre-authorisation of Treatment (Required):

Pre-authorisation of treatment by your insurance provider is required to confirm your appointment(s) and must be obtained at least 24 hours prior to your appointment. You can add the authorisation code or claim reference number below.

If your insurer does not provide an authorisation code or claim reference number, please email confirmation of your approved treatment (including number of sessions) to stephlyonsphysio@gmail.com prior to your appointment.

If this information is not provided at least 24 hours prior to your appointment and no response is received following a reminder from Steph Lyons Physio, your appointment will be cancelled. You are welcome to reschedule once the required information has been provided.

Name*

First NameLast Name

Date of Birth:*

Address (registered with insurance provider)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your insurance membership number:*

Your authorisation code/ claim reference number for treatment.*

Please note: It is your responsibility to ensure treatment has been pre-authorised by your insurer and that sufficient sessions are available. Any shortfall, excess, or non-payment by your insurer remains your responsibility, and any outstanding balance must be settled by you.

I confirm that I have obtained pre-authorisation from my insurer and understand I am responsible for any costs not covered, including any excess or shortfall.

Please confirm how many physiotherapy sessions have been authorised and whether this includes both initial and follow-up appointments*

4. Please use the space below to provide any further information that may be relevant.