Appointments 3 — Amanda Wellness Massage Therapy

Insurance Information

ins.ID #

date of injury

if so, in what state did the accident occur?

insured's full name

insured's date of birth

insured's employer

ins. IS #

employer's name/school name

primary insurance plan name

group number

plan number

Secondary insurance information

who is your attending physician?

name

fax

permission to consult with

regarding

your initials

fax

client agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that the american massage therapy association® has provided this form as a reference and is not held liable for any services provided.

electronic signature full name and date

assignment of benefits

I am responsible for all charges for all service provided. In the unfortunate event that my insurance company denies payment, or makes a partial payment, I am responsible for any balance due. If you, my massage therapist, have contracted with my insurance company at a discount rate for services, the amount remaining will be waived and I will not be asked to pay the balance. I authorize and direct payment of medical benefits to my massage therapist,

electronic signature full name and date

electronic signature of parent or legal guardian full name and date

if client is a minor

release of medical records

I authorize the release of medical records or other health care information, including intake forms, chart notes, reports, correspondence, billing statements, and other written information to my attorneys, healthcare providers, and insurance case managers, for the purposes of processing my claims.

electronic signature full name and date

electronic signature of parent or legal guardian full name and date

if client is a minor

(Please inform your practitioner immediately upon signing any exclusive Release of Medical Records with your attorney that may impact the above release statement.)

contact for care

I will participate fully as a member of my healthcare team. I will make sound choices regarding my sessions’ plan based upon the information provided by my massage therapist. I agree to participate in my own self-care programs and adhere to the plan we select. I agree to communicate with my practitioner any time I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of his or her skills and knowledge. I authorize and direct payment of medical benefits to my massage therapist,

electronic signature full name and date

electronic signature of parent or legal guardian full name and date

if client is a minor

This form was created as a resource by the american massage therapy association® and they are not held liable for any services provided.

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