Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Insurance InformationThis authorization form, when completed and returned, gives Your Counselling Ltd. permission to inquire to the below noted insurance company for the purposes of direct billing. By completing the information provided below, Your Counselling Ltd. is permitted to submit insurance claims on my behalf for the purpose of direct billing.Client File Name *FirstLastClient Date of Birth *Insurance Provider *Please Select Provider, If Other; Select OTHER and provide name in space belowAlberta Blue CrossGreenshieldCanada LifeASEBPBenevaBPA (Benefit Plan Administrators)Canadian Construction Workers UnionChambers of Commerce Group InsuranceCINUPThe CooperatorsCoughlin & Associates Ltd.D.A. TownleyDesjardins InsuranceEquitable LifeFirst CanadianIndustrial AllianceJohnston Group Inc.LiUNA Local 183LiUNA Local 506Maximum BenefitMedavie Blue CrossNexgen RxPeople CorporationSimply BenefitsSiriusTELUS AdjudiCareUnion BenefitsOtherIf Other:Policy Holder Name *Policy Holder Date of Birth *Relationship to Client *SelfParentSpouseOtherInsurance Policy Number ( or Certificate) *Group ID * Certificate) Birth File File Upload * Click or drag files to this area to upload. You can upload up to 3 files. Please upload a photo of the insurance card to allow for verification. If using a mobile device you can take a photo while completing this section. Authorization I hereby authorize Your Counselling Ltd. to submit insurance claims on my behalf for the purpose of direct billing. I consent to funds being paid directly to Your Counselling Ltd. for counselling services provided. I understand I am responsible for the full cost of the session if direct billing is not approved, and I will be invoiced for any outstanding balance not covered by my provider. Please note that we cannot guarantee the ability to predetermine coverage as not all providers offer this option. Additionally, coverage may change between the time of predetermination and when the claim is submitted. Coverage may change at any time during your engagement with Your Counselling Ltd. Click to indicate agreementYesContact Email *Contact Phone *Signature Clear Signature Submit
