Forms for Massage Clients
(206) 248-2001

Forms -
Everyone please start with Column 1

1st 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.

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

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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: Bring them !

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.

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. Pacificare and Am. Specialty Health Networks required forms only for their subscribers

  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

  13. ASHN Pain Indexes

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

Column 2

Same Day Pay

If you are planning to pay check, cash, or use Paypal.com at the time of your massage, please print and fill out only the forms in this column!

A. Click here and read Your Privacy & Your Rights

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 fax them to 206-431-5428. If you have any trouble faxing, please call 206-248-2001 we may just be on the internet. If you call us we will know to get off the internet so you can fax us!

Check list for
Same Day Pay

  • Did you read the privacy statement and sign the permission form? see A & B
     
  • Two items needed for your same day pay massage
  1. Signed privacy - I have read form
  2. Completed Medical History Intake form

Did you check if there was any current coupons or specials applicable?

Click here to go to our Newsletters page and then once there go to the most current issue.

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 insurance company for payment 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. Click here and read Your Privacy & Your Rights

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

B. Insurance

We will need to verify your insurance. Please either call 206-248-2001 or email us 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.

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 confirm your insurance 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. Please click Neck Pain Index OR Low Back Index, print, and fill out the indexes that apply to your pain/condition(s).  *ASHN has their own pain indexes click here.

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 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. Only if you have Pacificare, Health Net or American Specialty Health Networks plans, if not skip to J

*ONLY Pacificare, Health Net or American Specialty Healthy Network subscribers, please complete the additional forms: click on this link and then only on 3 and 6 and ONLY print pages 3 & 6 and fill them out.

J. Please remember to bring your completed forms to your appointment or fax them to 206-431-5428. If you have any trouble faxing, please call 206-248-2001 we may just be on the internet. If you call us we will know to get off the internet so you can fax us!

 

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 !