Electronic transmission authorization and consent form
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.
CLINIC NAME MAILING ADDRESS CITY, PROVINCE, POSTAL CODE
All About U Massage #5, 4513 – 52 Avenue Olds, AB CANADA T4H 1M8