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nt Information Patie

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Associated Bodywork & Massage Professionals
MEMBER
(page 1 of 2)
Practitioner/Clinic Name: ____________________ Billing Information
Contact Information: ________________________
Patie
nt Information
Name: ___________________________________________________ Date: _______________
Address: __________________________________________________________________________________
Phone: ___________________________________ Email: ____________________________________
Gender: ____________ Marital status: _____________ Date of birth: _________________
Social security number: _________________________ Date of injury: ________________
Referring healthcare provider: _________________________________________________________________
Phone: ___________________________________ Email: ____________________________________
Address: __________________________________________________________________________________
Primary Insurance Information
(e.g., Car Insurance if an auto accident, Worker’s Comp if an on-the-job injury, Health Insurance if an illness, etc.)
Insur
ance company: ______________________________________ Phone: _____________________
Address: _________________________________________________________________________________
Insurance ID# (include alpha prefix): _____________________ Group Plan #: _______________________
Name of insured (if other than you): _____________________________________________________________
Relationship to insured: __________________________ Insured’s SS#: ______________________________
Insured’s date of birth: ___________________________ Insured’s gender: ____________________________
Adjuster’s name: ________________________________ Phone: ________________ Fax: _______________
Secondary Insurance Information (if applicable)
Insurance company: ______________________________________ Phone: _____________________
Address: _________________________________________________________________________________
Insurance ID# (include alpha prefix): _____________________ Group Plan #: _______________________
Name of insured (if other than you): _____________________________________________________________
Relationship to insured: __________________________ Insured’s SS#: ______________________________
Insured’s date of birth: ___________________________ Insured’s gender: ____________________________
Adjuster’s name: ________________________________ Phone: ________________ Fax: _______________
Associated Bodywork & Massage Professionals
MEMBER
Practitioner/Clinic Name: ____________________ Billing Information
Contact Information: ________________________ (page 2 of 2)
Motor Vehicle Collision (Additional information is necessary if billing your car insurance)
Auto collision in what state? ____________________________
Job-related collision? Yes ☐ No ☐
Was the collision your fault? Yes ☐ No ☐
PIP policy amount: _______________ Dates of coverage: _____________ PIP available: ________________
MedPay policy amount: ___________ Dates of coverage: _____________ MedPay available: ____________
Liability policy amount: ____________ Dates of coverage: _____________ Liability available: _____________
Attorney Name (if applicable): ______________________________________ Date retained: ________________
Phone: __________________ Fax: _______________________ Email: _______________________________
Address: ____________________________________________________________________________________
Worker’s Compensation (Additional information is necessary if billing State or Federal Labor Insurance)
Have you received any massage/bodywork for this injury/claim? Yes ☐ No ☐
# of sessions: ____________ Date claim opened: ____________ Dates of coverage: ____________
Private Health (Additional information is necessary if billing your health insurance)
Does the insurance plan cover massage therapy? Yes ☐ No ☐
Does it cover massage therapy provided by a massage therapist (LMT, LMP, RMT, CMT, etc)? Yes ☐ No ☐
Does it cover massage therapy for this condition (____________________)? Yes ☐ No ☐
Does the treatment have to be referred? Yes ☐ No ☐ Prescribed? Yes ☐ No ☐
Does the treatment have to be pre-authorized? Yes ☐ No ☐
What is the annual massage therapy benefit (# of visits or $ amount)? ______________
How much is remaining for this year? _______________________
Do the benefit limits include PT, DC as well? Yes ☐ No ☐ How much is remaining for this year? ________________
What is the deductible? _____________ How much as been satisfied to date? _____________
Is there a co-pay? Yes ☐ No ☐ How much? _______________________
Does the massage/bodywork practitioner have to be a preferred/credentialed provider in the network? Yes ☐ No ☐
Is _________________________ a preferred/credentialed provider? Yes ☐ No ☐
Are there out-of-network benefits available? Yes ☐ No ☐
If yes, what % is covered/what is the co-insurance payment? ______________
What is the deductible for out-of-network care? _______________________
How much has been satisfied to date? __________________
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nt Information Patie

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Completed 7 July 2021

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