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  • RMQ Consent To Disclosure11

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    Paola Osuna
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    This document is a consent form from the Regroupement des massothérapeutes du Québec allowing a massage therapist, if contacted by a client's insurance company, to disclose only the reason for the client's consultation to the insurance company. The client can choose to consent or not consent to this disclosure by checking "YES" or "NO". It includes spaces for the client's name, date, and signature as well as the massage therapist's signature.

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    _RMQ__CONSENT_TO_DISCLOSURE11 (2)

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    This document is a consent form from the Regroupement des massothérapeutes du Québec allowing a massage therapist, if contacted by a client's insurance company, to disclose only the reason for the client's consultation to the insurance company. The client can choose to consent or not consent to this disclosure by checking "YES" or "NO". It includes spaces for the client's name, date, and signature as well as the massage therapist's signature.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    19 views1 page

    RMQ Consent To Disclosure11

    Uploaded by

    Paola Osuna
    This document is a consent form from the Regroupement des massothérapeutes du Québec allowing a massage therapist, if contacted by a client's insurance company, to disclose only the reason for the client's consultation to the insurance company. The client can choose to consent or not consent to this disclosure by checking "YES" or "NO". It includes spaces for the client's name, date, and signature as well as the massage therapist's signature.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    R MQ

    REGROUPEMENT DES 192 St-Joseph Street, Terrebonne Qc J6W 2Y7


    1 450 824-3550 — Toll free: 1 888 268-2516
    MASSOTHERAPEUTES Fax: 1 450 824-1887
    Website: rmqmasso.ca
    DU QUEBEC Email: anm.anpq@videotron.ca

    STRICTLY RESERVED FOR DULY REGISTERED MEMBERS

    CONSENT to DISCLOSURE FORM

    CLIENT :
    For future consultations, I allow the massage therapist,
    if contacted by my Insurance Company,
    to disclose only the reason for my consultation.

    YES NO

    Signed at _____________________________________________________________

    Name ________________________________________________________________
    IN PRINT LETTERS

    Date _______________________________________________________________

    Signature _____________________________________________________________
    CLIENT

    Signature _____________________________________________________________
    MASSAGE THERAPIST

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