Forms for Massage Clients
(206) 914-3885

Option 1 - for all clients: Please 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, please click here to go to that section and print them off, please fill them out and bring a newly filled out set to each of your massage appointments, so you can have more massage time and less paperwork 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.com 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

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.


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

D. Health information and Informed Consent required now at every massage therapy visit

E. 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 credit or debit card or flex spending card
  4. Health information and Informed Consent required now at every massage therapy visit

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 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 call your insurance plan directly.

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

D. Health information and Informed Consent required now at every massage therapy visit

E. 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.

F. Please click Health Status Update, print, and fill out the form.

G. Only if applicable to your condition/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).  

H. 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.

I. ONLY if you are a Kaiser patient, if not skip to J.

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

K. 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. Kaiser's Functional Rating Index only for Kaiser Patients

  9. Shorter medical history form for same day pay clients

  10. Sample Blank Billing Form

  11. HIPAA Privacy Violation Complaint Form

  12. Screening Questionnaire - taken via phone before session and required now at every massage therapy visit

  13. Arrival check-in screening protocol - taken verbally when you arrive and required now at every massage therapy visit

  14. Health information and Informed Consent required now at every massage therapy visit

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

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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 that be 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 these two forms

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 either scanning and emailing them to me at leilani @ leilanimassage.com (remove spaces) or bringing in your completed forms and having your payment ready when you come in for your massage appointment. If you want to pay by card we can do that over the phone before or after your appointment or even at the time of your massage service. 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 have printed off forms for them to fill out in person in the treatment room and they'll just do that using my cleanroom clipboard and pens that will all be sanitized after each session.

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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