Patient third party insurance information

We can only bill your primary insurance – If you have secondary insurance as well you can submit an invoice for the remainder, if any, to them manually.

Consent to Collect and Exchange Personal Information
Message to the Plan member, Spouse and/or Dependent regarding Personal Information
Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and / or plan abuse.

Instructions: This form must be filled out when claims are submitted electronically by the provider on the patient’s behalf. Please retain this form in the patient’s file for verification purposes for two years following closure of the patient file.

Provider: Flaman Physiotherapy
Address: 15-1945 McKercher Dr.
City/Province: Saskatoon, SK
Postal Code: S7J4M4
Phone Number: (306)374-2551