Massage Client Registration and Health Assessment

Susannah Graven LMT

Please correct the errors described below.

If you wish us to bill your session, please provide the following information:

Please Read:

I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. I understand that each therapist will separately prepare any necessary forms and billings to collect from my insurance carrier as a courtesy. Any amount paid to the therapist(s) will be credited to my account; however, I understand that I am personally responsible for my payment. If my insurance carrier or attorney makes payment directly to me, I agree to make equal and immediate payment to the therapist(s). A 1.5% per month finance charge may be added to any account over 90 days. I agree that my bill will be satisfied either by my insurance company, from the proceeds of any settlement or judgment or by me.

I authorize any insurance to pay any bills directly to the therapist(s) as an assignment of benefits and the use of the signature below on all my insurance submissions. I also authorize the release of all information necessary to secure the payment of benefits.

Cancellation Policy: Appointments are to be cancelled 24 hours in advance. If you do not show up for a scheduled appointment or cancel less than 24 hours prior to the scheduled appointment, the therapist with whom you were scheduled may charge a $30.00 cancellation fee. You are responsible for this fee, and it may not be billed to the insurance company.

I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder nor do they prescribe medical treatment pharmaceuticals, or perform thrust manipulations. I acknowledge that massage is not a substitute for medical examinations or diagnosis, and that it is recommended that I see a primary health care provider for these services.

I have read, understand, and agree to the above policy:

By typing your name in this box you agree to the above declaration

If this appointment is for a minor, then the parent or guardian must authorize treatment by signing below:

By typing your name in this box you agree to the above declaration

After you click on the submit button below, you will be returned to this page where you can click here to return to the MEDICAL PRACTICE FORMS page to complete your forms.

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