Susannah Graven LMT
Medford OR 97504
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.
If this appointment is for a minor, then the parent or guardian must authorize treatment by signing below:
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