Forms for Massage Clients
(206)
914-3885 call or text

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.

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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 debit/credit card/HSA t the time of your massage. You can even prepay when you book your appointment here

OR "Billed / Insurance" = you are planning to have our office bill your insurance company for your payment for your massage. For information on payment policies click here

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. (or you skip this step and you can fill out the medical history form online if you book your own appointment here )

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

 

 

 

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

B. Please read this, print and sign our Payment Policies and arrangements here.

C. Click here for Medical History, print, and fill out (or you skip this step and you can fill out the medical history form online if you book your own appointment here )

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?
     
  • The only items needed for your same day pay massage
  1. Completed Medical History Intake form and Payment Policies Arrangements
  2. Form of payment: check, cash or credit or debit card or flex spending card

You're ready for your massage appointment !

 

This is a copyright photo of one of Leilani'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.

B. Insurance

We recommend you verify your specific massage benefits which you can do by calling them (phone number is usually on your insurance card back) and asking the information 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. (or you skip this step and you can fill out the medical history form online if you book your own appointment here )

D. Please read this, print and sign our Payment Policies and arrangements here.

E. Referral or prescription

Almost all insurance plans require a referral or prescription (several even require prior authorizations) 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 you can plan to bring it with you to your massage appointment.

F. Please remember to bring your completed forms to your appointment or scan and email them to leilani @ leilanimassage.com or you can picture message them to my cell phone at 206-914-3885

 

Check list for Billed / Insurance clients:

  • Did you read the privacy statement
     
  • Items needed for insurance covered massage
  1. Completed Insurance Verification form
  2. Completed Medical History Intake form
  3. Do you have a referral or prescription from your doctor?
  4. Signed our Payment Policies and arrangements here.

Now you're ready for your massage appointment !

 

For Reference Only

Page Contents :

  1. Privacy Statement

  2. Medical History Intake

  3. Insurance Verification

  4. Blank Physician Referral Form

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

  6. Shorter medical history form for same day pay clients

  7. Sample Blank Billing Form

  8. Payment Policies

  9. HIPAA Privacy Violation Complaint Form

  10. Pain Indexes
    A. Health Status Update
    B. Neck Pain Index
    C. Low Back Index
    D. Headache Index