Fitmotive Insurance Form

First name

Last name

Email

Phone

Province

Is there a coach you'd prefer to work with?

Primary Insurance Company

Insured Services

Amount Covered (Percent)

Please list the amount of coverage and percentage per professional service. Plans range from covering 70% (or lower) to 100% of your services provided.

Is your mental health coverage grouped together, or are they separated individually for psychologists, social workers, and clinical counsellors?

Grouped Together

Divided

Is there a Masters Degree requirement? (If you have social work coverage, does the provider require a masters degree?)

Yes

No

Doctors Note

Some plans require a doctors note to be covered? i.e. for dietitian or occupational therapist? If you do, please list which services require one.

Do you have NIHB coverage?

Yes

No

I'm not sure

NIHB Coverage is for clients with active Treaty status only.

I acknowledge that it is my responsibility to verify the details of my insurance coverage. Fitmotive can provide receipts for eligible services, but cannot guarantee approval or reimbursement from my insurance provider.