Benefits Information - Timmins Family Counselling Center

I hereby authorize Timmins Family Counselling Center Inc. (TFCC) to share/disclose relevant information about me/my dependent with my insurance company as listed below via their electronic platform for the purpose of processing reimbursement for the counselling session(s) received at TFCC.

I understand that I am responsible to pay any expense that is not covered by my insurance benefit before leaving the establishment of TFCC.

I understand that I am responsible to inform TFCC of any insurance changes and/or concerns that I may have.

All information obtained is confidential between TFCC and my insurance company listed below.

This consent form is valid for a period of 12 months.

I Consent

Yes
No

Verify your consent by typing in your first and last name. This constitutes your signature.

Primary Insurance Carrier (Complete all that apply)

Name of the policyholder:

Their Date of Birth

Their Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Insurance Company Name:

Policy No:

Plan No:

Member ID:

Relationship to TFCC Client:

Client
Partner/Spouse
Child/dependant

Secondary Insurance Carrier (Complete all that apply)

Name of the secondary policyholder:

Their Date of Birth

Their Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Insurance Company Name: (copy)

Policy No:

Plan No:

Member ID:

Relationship to TFCC Client: (copy)

Client
Partner/Spouse
Child/dependant

Please include a copy of front and back of Benefit Card for our records.

File Upload

Click or drag a file to this area to upload.

Primary Insurance Carrier (Complete all that apply)

Secondary Insurance Carrier (Complete all that apply)

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