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Please determine your massage benefits by calling the customer service # on your card.
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1
Patient's Name:
your full name
Date of birth
Email
a valid email
Phone Number
360 -555-5555
Does your insurance policy cover Massage Therapy performed by an LMP?
yes
no
Does Treatment have to be referred?
yes
no
Who is the Primary Care Physician (PCP)?
Who can refer/prescribe Massage Therapy?
Does the plan require pre-authorization?
yes
no
Authorization and reports should be sent to:
Phone Number
360 -555-5555
Fax Number
360 -555-5555
What is the annual Massage benefit and/or limits?
$2500 | No Limits
Do the benefit limits include treatment by a PT? and/or Chiropractor?
PT
Chiro
What is the deductible?
has it been met?
yes
no
If the deductible has NOT been met, what is the remaining amount?
Is there a co-pay?
yes
no
If yes, how much
Does the LMP have to be a Preferred Provider?
yes
no
Is one of our LMPs on the preferred provider list?
yes
no
which provider
pick one!
If so, which one?
Teri Anderson
Diedra Dulaney
Sean Loehr
Amanda Robinson
Are there “out of network” benefits?
yes
no
If yes, what %
Is the deductible the same?
yes
no
If no, the amount?
Is the annual Massage benefit limit the same?
yes
no
If no, the amount?
Claims must be sent to:
Claims must be sent to:
Please bring this form with you to your next massage appointment, so it can be added to your medical file.
By checking the box below your are authorizing your signature online with
Flutura Healing
Please bring this form with you to your next massage appointment, so it can be added to your medical file.
By checking the box below your are authorizing your signature online with Flutura Healing
Yes, I agree
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