EmailMe Form - Patient Direct Billing Auth

Name *

First Last

Email *

Phone *

### - ### - ####

Date of Birth *

MM / DD / YYYY

Emergency Contact

Name *

First Last

Relationship *

Home Phone *

### - ### - ####

Work Phone

### - ### - ####

Patient Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Extended Healthcare Benefit Plan Information

Benefit Provider Name: *

Ex. Bluecross, etc.

Insurance Plan ID *

Policy Number *

Planholders Name *

Patient Name *

Other Benefit Plan Info

If your benefit plan card shows any other info, name it and enter here.

I allow the therapists at Blend Wellness aka the Marie Milne Skin Clinic and the Edmonton Rejuvenation Spa at 13457 149 St, Edmonton, AB to use the information in this form to determine my benefit plan eligibility. I understand and I give consent to the direct billing of my benefits and that I shall be billed with the information listed here. No billing will occur until I have received the treatment booked and thereafter. I agree that if payment is sent to me that I will immediately forward this to my therapist at: Blendwellness@gmail.com (use password: Edmonton123). I also agree to keep my treatments and details of services confidential. I shall check in with my massage therapist first prior to disclosing any information to insurance, associations, or any entity petitioning information about these sessions from me.

I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the 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 Assignment, that any benefit payment made in accordance with this Assignment 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 the 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 Provider. *

I agree

Questions or concerns? Call us: (780) 432-5900