3rd Party Funding Declaration

For clients funding their services through an insurance or medical policy or receiving funding from a 3rd party please complete this form. We are unable to deliver any services until we have all the relevant information.

Please ensure you have also completed a client registration form.

Funding Type:*

InsuranceEmployerOther

Referral or Case URN (if known)

This will start REF-XXXX-2018 or CAS-XXXXX-XXXX

Your Name*

First NameLast Name

Home Post Code

Email Address*

example@example.com

Phone Number*

Area CodePhone Number

Medical Insurance Policy

Each medical or insurance policy is unique to its member and so we encourage all clients to read carefully the terms and conditions of their insurance policy.

We ask all members to provide consent to enable us to contact your insurance company to confirm eligibility to receive services from us.

Should our fees not be covered in full by your insurance company you agree to settle any outstanding fees directly to The Practice MK upon receipt of our invoice.

Insurance Company

If you have medical insurance with a company that is not listed please contact us on 01295 236262 to proceed

Policy / Member Number

Authorisation Number

Session Limit

Is there an excess due on under the terms of your policy?

YesNoI don't know

Excess Amount

Often an excess is applicable which must be paid directly to the Family Practice Group. If this is the case please provide a credit or debit card so that we may charge any excess due. Payments will be charged following your first appointment with us.

EXCESS PAYMENTS - PLEASE NOTE

Most policies include an excess that is payable. As you have chosen "I dont know" we urge you to contact your insurance company to confirm if an excess is due prior to your starting sessions. Any excess payable will be due to the Family Practice Group and is charged during treatment

I consent to the Family Practice Group charging my credit or debit card for the amount of any excess due following my first appointment.

I Consent

Your credit or debit card will not be charged until you have attended your first appointment.

Pre Pay Method(£ Free for each day)

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

3rd Party Funding

For clients whose fees are being paid by an employer or 3rd party we require consent to contact the authorised person responsible for your fees to confirm the amount of funding available.

We will ask them to confirm in writing they agree to be responsible for your fees. We are unable to confirm appointments until we have this.

Should our fees not be covered for any reason you agree to settle any outstanding fees directly to the Family Practice Group upon receipt of our invoice.

Company / Organisation

Contact Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

By checking the box below you give the Family Practice Group consent to contact the above organisation and representative to confirm funding for your services. We will not discuss any other matter without further consent from yourself.

Yes, please contact themNo, I do not wish to proceed

Please provide your signature below*

3rd Party Fees Declaration