We direct bill most insurance companies; however, each plan is different and may not allow us to submit a claim on your behalf. Be sure to verify your plan.

The following statement provides stipulations and consent for Urban Massage & Wellness to submit a claim to third-party insurance on your behalf:

Personal information collected and disclosed by the aforementioned clinic, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for purposes such as assessing claims, underwriting, investigating, auditing, and administering the group benefits plan, including the investigation of fraud and/or plan abuse. I hereby assign benefits payable for the eligible claims to the provider responsible for submitting my claims electronically to the benefit 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 the payment to the provider for any services rendered and/or supplies provided.

I acknowledge that the insurer/plan administrator is under no obligation to accept this assignment. Any benefit payment made in accordance with this assignment will discharge the insurer/plan administrator of its obligation with respect to that benefit payment. 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 confirm that I am authorized by my spouse and dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above. I also confirm that my spouse and/or dependents authorize the insurer and their service provider(s) to disclose information about their claims to me for the purposes of assessing and paying a benefit, and managing the group benefit plan. Additionally, I authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider.

In the event of suspicion and/or evidence of fraud or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization, including law enforcement bodies, regulatory bodies, government organizations, medical suppliers, and other insurers, and where applicable, my plan sponsor, for the purposes of investigating and preventing fraud and/or plan abuse. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my plan sponsor, for that purpose.

I authorize the clinic and healthcare provider to collect, use, and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. I authorize the plan administrator and service provider(s) to use my personal information for the above purposes, including but not limited to sharing personal information with any individual or organization when relevant for the above purposes, and exchanging personal information electronically or in any other manner. I understand that personal information may be subject to disclosure to those authorized under applicable law and that a photocopy or electronic version of this authorization shall be valid as the original. This authorization may remain in effect for the continued administration of the group benefit plan.