Direction to Pay

Submit your direction to pay form to authorize direct billing to your insurance provider.

Direction to Pay Authorization

Please complete the form below to authorize painPRO Clinics to bill your insurance provider directly on your behalf.

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Address

City

Province

Postal Code

Insurance Provider *

Policy/Group Number *

Certificate/ID Number *

Plan Member Name (if different)

Relationship to Plan Holder

Preferred Clinic Location *

Services (Select all that apply)

Massage Therapy Physiotherapy Kinesiology Chiropractic Acupuncture Counselling

By signing below, I authorize painPRO Clinics to:

I understand that I am responsible for any balance not covered by my insurance plan.

Digital Signature (Type your full name) *

Date *

All information is kept confidential and secure.

Your personal and insurance information is encrypted and handled with the utmost care and confidentiality.

We process direction to pay forms within 1-2 business days and will notify you once your file is set up.

Once set up, we bill your insurance directly. You only pay any remaining balance not covered by your plan.

If you have questions about the direction to pay process or need assistance with the form, our team is here to help.