Intake, Consent, & Benefits Information

Insurance Information
Primary Insurance
Policy Holder's Name
Policy holder’s date of birth:

MonthDayYear
Date
Your insurance company/carrier:
Group, policy, or contract number:
Certificate or Member ID number:
Division ID (Empire Life only)
Client Relationship to Member
Secondary Insurance (if applicable)
Policy holder’s name:
Policy holder’s date of birth:

MonthDayYear
Date
Your insurance company/carrier:
Group, policy, or contract number:
Certificate or Member ID number:
Division ID (Empire Life only)
Client Relationship to Member

Insurance and Direct Billing Authorization

If I choose to provide insurance information (Primary and/or Secondary), I understand it is used to help submit benefit claims and/or attempt direct billing where available. I understand coverage and payment are determined by my insurer and are not guaranteed.
Consent to Collect, Use, and Disclose Information for Insurance Claims: I authorize Masahista Healing Hands to collect, use, and disclose my personal information (and health information where required) and any plan member/policy holder information I provide (e.g., name, date of birth, insurer/carrier, group/policy number, certificate/ID number, relationship) for the purpose of verifying benefits (where applicable) and submitting, assessing, administering, auditing, and investigating insurance claims, including the prevention/investigation of fraud or plan abuse. This information may be disclosed to my insurer/plan administrator and their service providers for these purposes. If I am not the plan member/policy holder, I confirm I have their permission to provide their information and to authorize claim submission for the purposes stated above.
Direct Billing Authorization and Payment Responsibility: If direct billing is attempted, I authorize Masahista Healing Hands to submit claims to my Primary insurer and, if applicable, my Secondary insurer. I understand I am responsible for all fees not covered or not paid by my insurer(s), or if payment is not made directly to the provider, and I agree to pay any balance owing.
Card on File: If I have provided a payment method, I authorize the clinic to securely store it and charge any outstanding balance related to this appointment/claim if an amount remains owing after insurance processing.
Marketing Consent

(optional)
I agree to receive e-mail marketing and promotional communications from Masahista Healing Hands. I understand I can unsubscribe at any time.
I consent to Masahista Healing Hands sharing my email/phone with its marketing agency and ad platforms for audience matching/ad measurement (may be hashed). I can withdraw consent at any time.
Digital Signature (Typed Full Name) If the client is under 18, a parent/legal guardian must type their full name here.
Today's Date

MonthDayYear
Date
Should be Empty:

Intake, Consent, & Benefits Information

GENERAL INFORMATION

MASSAGE INFORMATION

MEDICAL INFORMATION

Informed Consent

Specialty Services Consents

Professional Conduct

Appointment Guidelines

Insurance Information

Insurance and Direct Billing Authorization

Marketing Consent