Forms for Massage
1st Decide how you will be paying for your massage.
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.
Everyone start with:
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.
2nd: Pick your column
Same Day Pay Column 2
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.
Leilani took these pictures at the Mt. Vernon Orchid Show Feb. 2007.
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!
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!
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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 !
is a copyright photo of one of Leilani Berry's
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.
Then click here for privacy permission, print, and fill out.
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.
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.
*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!
Now you're ready for your massage appointment !