Direct Billing Information & Consent

Required Field

Personal Info

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Insurance

I have insurance

Insurer

Policy Name

Policy / Group / Plan #

Member ID / Certificate #

Policy Holder

I'm not the policy holder.

First Name

Last Name

Relationship To Patient

Date of Birth

Address

City

Prov / State

Postal / Zip Code

Phone Number

Prescriber

First Name

Last Name

Other

Additional Insurance Information:

If you have a prescription from your Doctor, what is the date of the prescription? (*Please note* Prescription must be brought to your appointment to be used)

Characters: 0/255

If you are not the policy holder for the above insurance, please provide the policy holder's date of birth:

Characters: 0/255

Secondary Insurance

Insurer

Characters: 0/255

Policy/Group Number

Characters: 0/255

Member ID/Certificate Number

Characters: 0/255

Policy Holder's First and Last name

Characters: 0/255

Policy Holder's Date of Birth

Characters: 0/255

Relationship to Policy Holder

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Direct Billing Policy, Assignment of Benefits Authorization & Consent Form (Review Required)

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