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My Account
Cart
0
Services
Memberships
Body Treatments
Facials
Hair Removal, Tinting, & Lamination
Massage
Nails
Packages
Peels & Microdermabrasion
Mobile Massage
About Us
About Us
Meet Our Staff
Loyalty Program
Team
Insurance
Shop
Blog
Follow
Instagram
Facebook
Compassionate Service To Enrich Your Life
Client Name
*
First and Last
Date of Birth
*
MM/DD/YYYY
Current Coverage?
*
Yes
No
Is this a medicare/medicaid plan?
Yes
No
Name of Insurance Company
*
Insurance ID Number
*
Insurance Phone Number
*
Employer
*
Subscriber Employer
Effective Date of Policy
*
MM
DD
YYYY
Copay Amount
*
In and Out of Network Benefits
Is there a time limit for each visit?
*
No limit
60 minutes
90 minutes
Massage Reimbursed at What %
*
Reimbursement Cont'd
*
% of Allowable
Billed Amount
Fee Schedule
Is prior authorization required?
Yes
No
Subject to First Meeting a Deductible?
*
Yes
No
If Subject, Deductible Amount
Calendar or Plan Year
*
Calendar Year
Plan Year
Dates of Plan Year From:
MM
DD
YYYY
Dates of Plan Year To:
MM
DD
YYYY
Massage Limit/Number of Visits
*
Used to Date
*
Remaining Visits
*
Combined Benefit
Yes
No
Coverage
*
Primary
Secondary
Other Notes?
Secondary Plan Client Name
Secondary Plan ID Number
Secondary Plan Group Number
Thank you!
