Forms for Massage Clients
(206) 914-3885

Step 1: Everyone please start with Column 1

Step 2: Decide how you will be paying for your massage. 

                    Options for payment are
                    "Same Day Pay" OR "Billed / Insurance" 
                    Click here to read more information on Payment Options

 

Optional: Click Here for Page Contents a list of all the available forms furnished by our office.

To view PDF files, you must have the Adobe Acrobat Reader.  If you do not already have the Acrobat Reader installed, please go to Adobe's Acrobat download page now.

Leilani took this picture at the Mt. Vernon Orchid Show Feb. 2007.
 
Column 1

Everyone start with:

1st: Payment

Decide how you will be paying for your massage.

Options for payment are

"Same Day Pay" = you are planning to pay check, cash or use Paypal.com at the time of your massage.

OR "Billed / Insurance" = you are planning to have our office bill your insurance company for your payment for your massage.

Click here if you would like to read more information on Payment Options

2nd: Pick your column

Same Day Pay Column 2

OR

Billed/Insurance Column 3

3rd: If you want you can fill out your forms and bring them to your massage session, saving you time!

Please do not forget to bring your forms with you or you will just have to fill them out again when you arrive.

Thank you for your patience and thoroughness with your forms. This process helps us save you time and process your bills.

 

 

Leilani took these pictures at the Mt. Vernon Orchid Show Feb. 2007.
Column 2

Same Day Pay

If you are planning to pay by check, cash, or use Paypal.com
at the time of your massage, please print and fill out only the forms in this column!
A. Read this here and read Your Privacy & Your Rights. You do NOT need to print this form.

B. Click here for privacy - I have read, print, and fill out.

C. Click here for Medical History, print, and fill out

D. Bring completed forms to your appointment or scan and then email them to leilani @ leilanimassage.com.
 

Check list for
Same Day Pay

  • Did you read the privacy statement and sign the permission form? see A & B
     
  • Three items needed for your same day pay massage
  1. Signed privacy - I have read form
  2. Completed Medical History Intake form
  3. Form of payment: check, cash or paypal.com account

You're ready for your massage appointment !

 

This is a copyright photo of one of Leilani Berry's
hot stone massage sessions.

 
Column 3

Billed / Insurance

If you are having our office bill your insurance company or attorney or third party for your massage, please print and fill out only the forms in this column that apply to you & your insurance company.

Please read all the way through to see if each item applies or not A through H.

A. Read this here and read Your Privacy & Your Rights . You do NOT need to print this form.

* Then click here for privacy permission, print, and fill out.

B. Insurance

We may need to verify your insurance. Please either call 206-914-3885 or email leilani @ leilanimassage.com the information listed on this form click here for the insurance verification form. 

This way we can make sure you have massage benefits and whether or not you need a referral from your doctor prior to your appointment. You may also have to pay a deductible, copay or coinsurance at the time of your massage. These details of the insurance plan are decided by your insurance plan and your plan selection. If you want more details, please feel free to call us or your insurance plan directly.

C. Click here for Medical History Intake form, print, and fill out the form.

D. Referral or prescription

Almost all insurance plans require a referral or prescription for massage therapy treatment.

Prior to your appointment, please either call to your doctor's office or your insurance to confirm the insurance company has received the referral/prescription from your doctor or plan to bring it with you to your massage appointment.

If you do not have a referral/prescription, click here for a blank referral form, print it, and have your doctor fill it out for you.

E. Please click Pain Index, print, and fill out the form.

F. Only if applicable to your pain, please click Neck Pain Index AND/OR Low Back Index AND/OR Headache Index, print, and fill out the indexes that apply to your pain/condition(s).  

G. ONLY if you were in an auto accident or on-the-job injury, if not skip to H

*ONLY auto accident or on the job injury incident clients, please REMEMBER to bring your claim information including the insurance company's telephone number and your claim number.  You will definitely need referral for treatment see D above.

H. ONLY if you are a Group Health patient, if not skip to I.

*ONLY Group Health Patients, please complete the following form: click here for the FRI form, print it, and fill it out.

I. Please remember to bring your completed forms to your appointment or scan and email them to leilani @ leilanimassage.com.

 

Check list for Billed / Insurance clients:

  • Did you read the privacy statement and sign the permission form?
    see A in this column only
     
  • Items needed for insurance covered massage
  1. Signed privacy permission form
  2. Completed Insurance Verification form
  3. Completed Medical History Intake form
  4. Do you have a referral or prescription from your doctor?
  5. Did you fill out the pain indexes? items E & F?
  6. Items G through I ONLY if they apply to you.

Now you're ready for your massage appointment !

 

For Reference Only

Page Contents :

  1. Payment Options

  2. Privacy Statement

  3. Privacy - I have read

  4. Privacy - Permission Form

  5. Medical History Intake

  6. Insurance Verification

  7. Blank Physician Referral Form

  8. Group Health's Functional Rating Index only for Group Health Patients

  9. Shorter medical history form for same day pay clients

  10. Sample Blank Billing Form

  11. HIPAA Privacy Violation Complaint Form

  12. Pain Indexes
    A. Pain Index
    B. Neck Pain Index
    C. Low Back Index
    D. Headache Index