Extended Health Benefits Form

In order to direct claim with our clinic, you must send us the following information.

You can find the following information on your plan’s website OR in your insurance booklet.

If you have any questions, please contact us at (778) 903 7707 or at aurahealingbeauty@gmail.com

To ensure that the direct billing process goes as smoothly as possible, please also send a photo of your pay-direct card and your benefits summary to our email (aurahealingbeauty@gmail.com).

Name

Please put in your FULL LEGAL NAME

First Name

Last Name

Date of Birth

YYYY

Coverage for

If you have coverage for both RMT and Acupuncture, please send us ALL the information below.

Insurance Company

Primary Coverage Policy Number

(also referred to as a group or contract number)

Primary Coverage Certificate Number

(also referred to as member/identification number)

Primary, Spouse or Dependent?

Name of Primary Insured Member

Who is the insurance policy under? Please put in their FULL LEGAL NAME

First Name

Last Name

Primary Insured Member's Date of Birth

YYYY

Annual Maximum

(e.g: $400 for RMT, $500 for Acupuncture)

One Service Maximum (if any)

Deductible (if any)

% of Coverage

Remaining Amount of Coverage

Time period for benefits

(e.g., benefits renew after 12/31)

Extended Health Benefits Form

AURA Healing Medi Clinic

Clinic Hours

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