Forms for Massage Clients
(206) 914-3885

Option 1 - for all clients: Please text at 206-914-3885 or email us at leilani @ leilanimassage.com (remove spaces) and we will get you set up with our Hands Heal electronic health records system and you can fill all your forms out ahead of time. We will need your email address, birthdate, full name and phone number to get your records started and then we will email you with a welcome to the electronic health records portal and you can begin filling out your forms ahead of time. That means more massage time for you!
 

Option 2: For any reason you are unable to do the electronic records option. For example, you do not do do email or share an email with other people. Then you need to start below with column 1 and then decide how you will be paying for your massage going on to column 2 or column 3.
                    Options for payment are
                    "Same Day Pay" OR "Billed / Insurance" 
                    Click here to read more information on Payment Options

For those that are unable to do Hands Heal electronic records system, we will still need forms at every visit even after your first visit because of COVID. If you are a returning client scheduling subsequent massage appointments and unable to do electronic health records, not to worry we will file them out together when you arrive at your appointment time. Thank you.

Optional: Click Here for Page Contents a list of all the available forms furnished by our office.
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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 your debit, credit or flex speanding card using swipe or over the phone or Paypal or Venmo at the time of your massage, before or after 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


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Column 2

Same Day Pay

If you are planning to pay by check, cash, or use your debit or credit card to pay for your massage
at the time of service, 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. The rest of your forms are with Hands Heal Electronic Records.
 

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. Completed Client Information, Wellness Intake, Covid screening form at Hands Heal Electronic Records
  2. Form of payment: check, cash or credit or debit card or flex spending card
  3. Facial Mask

You're ready for your massage appointment !

 

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Column 3

Billed / Insurance

If you are having our office bill your insurance company or attorney or third party for your massage, 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 - please verify your insurance coverage using these questions for the insurance verification form. You 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.

C. Completed Client information, treatment intake, billing and insurance, and covid screening forms at Hands Heal Electronic Records.

D. You can picture message a copy of your referral or prescription to 206-914-3885 or email a copy to leilani @ leilanimassage.com (remove the spaces)

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

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. *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.

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. Completed Client information, treatment intake, billing and insurance, and covid screening forms at Hands Heal Electronic Records.
  2. Do you have a referral or prescription from your doctor?
  3. If auto accident or L&I do you have your claim info?

Now you're ready for your massage appointment !

 

For Reference Only

Page Contents :

  1. Payment Options

  2. Privacy Statement

  3. Privacy - Permission Form

  4. Insurance Verification

  5. Blank Physician Referral Form

  6. HIPAA Privacy Violation Complaint Form

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Regarding electronic health records, no worries there will always be clients who aren't up to doing the tech of electronic records. The governing powers want us to get away from handling paper and payment at the time of services for lots of reasons not just covid and risks of frequently touched surfaces & proximity. But I have two options for clients that are not going to do electronic health records.

First don't stress when the system emails you, please just consider them reminders for your upcoming appointment.

For new clients, please follow directions above for forms. For returning and subsequent appointments, I will only need two types forms similar to these two Health information and Informed Consent and Health Status Update

Option one (next best thing to the electronic health records) is printing off your forms and filling them out ahead of time and scanning and emailing them to me at leilani @ leilanimassage.com (remove spaces) and having your payment ready when you come in for your massage appointment. What's great about this option is that you still get more massage time!

Option two. Some clients can't print off forms or do any of it ahead of time so I'll always help you fill out the electronic forms when you arrive for your appointment. Please note that I will be using Hands Heal electronic health records even if you do not ever interact with the Hands Heal Electronic Health Records system other than to receive appointment reminders. Electronic health records are one of the ways health providers are supposed to be working in COVID times and eventually electronic records will be required of providers (not required patients.) If you are concerned about your privacy and safety of your records, you can read up on the privacy policy of the system I will be using here https://www.handshealehr.com/documents/policy.pdf and my privacy policy here.

Thank you so much for your understanding and patience.

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