Medical Massage/Insurance

Client Information

Name

Date of Birth

Phone Number

Address

Insurance Information

Insurance Provider

Policy Number

Group Number

Insured Name (if different from client)

Secure Image Upload: Insurance Card (Front & Back ) & Identification Card

Financial Responsibility Statement:

I, the undersigned, understand and agree to the following:

Insurance Verification

I understand that it is my responsibility to verify my insurance coverage for medical massage services. I will confirm with my insurance provider whether medical massage therapy is a covered service and if pre-authorization is required.

Copayments and Deductibles

I understand that I may be responsible for copayments, deductibles, or coinsurance that are outlined in my insurance plan. These payments are due at the time of service unless otherwise arranged.

Non-Covered Services

I acknowledge that if my insurance provider deems any services rendered as non-covered, I will be responsible for the full payment of those services.

Outstanding Balances

I agree to pay any outstanding balances not covered by insurance within 30 days of receiving a statement.

Cancellation Policy

I understand the cancellation policy for appointments and agree to notify the clinic at least 24 hours in advance to avoid potential cancellation fees.

Payment Plan

If applicable, I understand that I can request a payment plan for any outstanding balance, which will be discussed and agreed upon with the clinic.

Consent to Bill Insurance

I authorize the clinic to bill my insurance provider directly for the services rendered. I understand that my signature below serves as my consent for treatment and for billing my insurance.

Client Signature

Client Date

Insured Signature (if different)

Insured Date

Health Insurance Claim Processing

Eligibility Check (1-2 Days)

Provider’s Role: The provider’s office will verify your insurance coverage, checking the specifics of your policy, including coverage limits.
Insured’s Role: You will need to provide your insurance card, identification card and any relevant personal information. Prompt communication can speed up the process.
Outcome: You’ll receive confirmation of your eligibility, allowing you to move forward with the next steps.

Pre-Authorization (2-5 Days)

Provider’s Role: If the service requires pre-authorization (common for specialized treatments), the provider will submit a request to your insurance company, detailing the medical necessity, treatment plans and any required referral from your physician. (see prescription examples)
Insurer’s Role: The insurer reviews the request, which can involve additional documentation. This step varies in length based on the insurer’s processing time and the complexity of the case.
Insured’s Role: Stay informed; if the provider requests additional information from you, responding promptly can help expedite the process.
Outcome: You’ll receive a notification about the approval or denial of the pre- authorization, including details about coverage and costs.

Cost Estimation (1-3 Days)

Provider’s Role: After obtaining pre-approval, the provider generates a cost estimate based on the approved service, itemizing costs such as co-pays, deductibles, and potential out-of-pocket expenses.
Insured’s Role: Review the estimate carefully and ask questions about any unclear charges or terms.
Outcome: You’ll have a clear understanding of your financial responsibilities before proceeding.

Finalizing Service Booking (1 Day)

Booking the Appointment: Once you’re comfortable with the cost estimate, you can book the service. This can be done online.
Confirmation: The provider will confirm your appointment and ensure all necessary pre- authorization and insurance paperwork is complete.

Overall Time Frame (5-11 Days)

The entire process, from initial eligibility checks to booking your service, generally takes 5 to 11 days. This timeline highlights the importance of communication and organization, both from the provider and insured, to ensure a seamless experience in navigating health insurance claims. By being proactive, you can help streamline the process and focus on your health needs.

Please Note: If the provider is not listed in-network with your health insurer’s plan, it may still be possible to submit the claim through your insurer’s online portal or by contacting them directly. After your service is complete and payment is made, be sure to request a detailed service statement from your provider—this is essential for your insurance submission!

HSA FSA Accepted

Massage Prescription Examples

Date

Your Name
Your Address
Your Email Address

Your Date of Birth
Your Patient ID or Account Number (if applicable)

Your Phone Number

Physician’s Name
Practice Name
Practice Address

Example 1

Dear Dr. (Physician’s Name),

I hope this message finds you well. I am writing to request your support in obtaining a prescription for massage therapy to promote my general well-being.

I believe that regular massage therapy could provide significant benefits for my overall health, including stress relief, muscle relaxation, and improved mental clarity. As we have discussed in previous appointments, I am committed to maintaining a holistic approach to my health, and I feel that incorporating massage therapy would be a valuable addition.

If you agree that this could be beneficial for my well-being, I would greatly appreciate your assistance in providing a prescription for massage therapy.

Thank you for considering my request. I look forward to your response and appreciate your continued support.

Sincerely,
Your Name

Example 2

Dear Dr. (Physician’s Name),

I hope this message finds you well. I am writing to discuss my current health situation and to request your support in obtaining a prescription for massage therapy.

As we have previously discussed, I have been experiencing (briefly describe your condition, e.g., chronic muscle tension, stress, etc.). I believe that incorporating massage therapy into my treatment plan could help alleviate some of these symptoms and improve my overall quality of life.

I have researched the potential benefits of massage therapy, particularly in relation to (mention specific aspects related to your condition, e.g., muscle relaxation, stress reduction, improved circulation), and I am hopeful that it could be a valuable addition to my current treatment.

If you agree that this approach may be beneficial, I would greatly appreciate your assistance in providing a prescription for massage therapy.

Thank you for your attention to this matter. I look forward to your guidance and appreciate your ongoing support in managing my health.

Sincerely,
Your Name

Post-Service Care

Hydrate

Drink plenty of water after your session to help flush out any toxins.

Rest

Allow yourself time to relax and integrate the experience. You may feel more tired than usual.

Avoid Intense Activity

Refrain from strenuous exercise or stressful situations for the remainder of the day.

Journaling

Consider journaling any thoughts or feelings that arise after the session to aid in processing your experience.

Medical Massage/Insurance