Attention: Due to complications resulting from the pandemic, we only offer home-based therapy at this time. Many of the forms on our website are not currently in use. This is an archived webpage.
*Please note*
This is an archived post and contains information that may be out of date. We no longer accept insurance for massage therapy services.
______________________
Kaiser Permanente and HMSA: Forms (2) for ASH Group health insurance massage reimbursement clients
UHA members: All 4 forms need to be received in order for me to submit your treatment plan for approval. This process may take up to 15 days
- Financial Contract This form is necessary in order for me to communicate and bill your insurance provider. I do not need a credit card on file if you agree to my cancelation policy.
- Intake Form
- Assessment Form
- Please also select one or more of the following forms if any are applicable to your diagnosis or injury. Neck Pain, Lower Back Pain, Shoulder Arm Hand or Upper Extremity Pain, Leg Foot or Lower Extremity Pain
Forms for No-fault Auto or Workers' Compensation
- Fill out the on-line information form for pre-authorization by scrolling down to the bottom of this page on my site. After I speak with you on the phone, fill out the following intake form and financial contract. Make sure not to email any forms that have your credit card number printed on them.
- Intake Form
- Financial Contract and Release
- Please also select one or more of the following forms if any are applicable to your diagnosis or injury. Neck Pain, Lower Back Pain, Shoulder Arm Hand or Upper Extremity Pain, Leg Foot or Lower Extremity Pain
HMAA members: one form
Custom Massage Form for out of pocket clients
- 🌴🌴🌴 Short Intake Form 🌴🌴🌴 (If you are paying out of pocket for a custom massage and have an uncomplicated medical history, you can fill out this abbreviated health form. )
Additional Assessment Forms
- Neck Pain
- Lower Back Pain
- Shoulder, Arm, Hand, and other upper extremity pain
- Leg, Foot, and other lower extremity pain