Client Intake Form
All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
United Health Care Student Resurce covers massage therapy for Injury Treatments only. Your therapist will only see you for the treatment you reported to your insurance. Relaxing massages are not covered through your UHCSR insurance. UHCSR would only acept injuries that have happened during the time period you are insured.
Please answer the questions below, accordingly to the injury report given by you to the insurance.
To Complete Injury Report go to www.UHCSR.com/myaccount
(1) Log-In (Using your UHCSR user name and password)
(2) Go to “My Claims” tab
(3) Choose “Manage Accident Details” tab
(4) Select “Submit Accident Details” link
(5) Send us a screenshot of the completed form at firstname.lastname@example.org
Prior Day Notice is required for all Cancelations to avoid being charged a cancelation fee of $22. Cancellation fees will be charged to your card on file. Patient balance cannot be added on to your student’s account.
EXCLUSSION AND LIMITATIONS
Your insurance will not cover: Auto Accident Cases, Work Injury, Intercollegiate, professional sport contest or competition, and Pre-Existing Conditions.
For more exclusions and limitations go to
Policy Option 2: https://www.uhcsr.com/uhcsrbrochures/Public/BenefitSummaryFlyers/2018-625-2%20Summary%20Brochure.pdf
Policy Option 3: https://www.uhcsr.com/uhcsrbrochures/Public/BenefitSummaryFlyers/2018-625-3%20SB.pdf
Regular Rates 30 minutes $3560 minutes $5590 minutes $80
SAU Students or Seniors Over 65 yrs Old30 minutes $3560 minutes $4590 minutes $70
To Obtain Disccount, You Must Provide SAU Student ID (SAU Students), Drivers Licence or State Identification Card (Seniors).
ARM: For Extra 30 min Therapy $25 each
UHCSR POLICY OPTION 3 (2018-625-3): $35 Copay each visit
Please check any symptoms that apply to you and indicate right or left when applicable:
Client services and chart information are confidential. Written authorization is required from you to release any information.
• Please turn off your cell phone for optimal relaxation
• Your scheduled session is set aside for you.
• 24 hour cancellation notice is required to avoid being charged for your session
• You will be draped and at no time will genitalia or breast tissue be exposed
• You will have a consultation with your therapist to discuss your session
• After your therapist has left the room, you may disrobe to your comfort level
• I understand that my therapeutic massage therapist or I may end the session at any time for any reason
• Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law
Assignment of Benefits:
The undersigned patient and/or responsible party, in addition to continuing personal responsibility, and in consideration of treatment rendered or to be rendered assigns to Pro Health the following rights, power, and authority.
WEB-TPA THROUGH ADVENTIST RISK MANAGEMENT: Patient must be over 18 years old and have ARM-Accelerate policy to obtain the benefit.
UHCSR ACCIDENT DETAIL REPORT: Upon your first visit with us as a United Health Care Student Resource Client, you must go online to your MyAccount and fill out an accident detail report. If you do not fill out this report, you willbe held responsible for the services that were rendered to you.
INFORMATION RELEASE: You are authorized to release information concerning my condition and treatment to my insurance company, attorney, or insurance adjuster, for the purpose of processing my claim for benefits and paymentof services rendered to me.
IRREVOCABLE ASSIGNMENT OF RIGHTS: You are assigned to exclusive, irrevocable rights to any cause of action that exists in my favor against any insurance company for benefits to the extent of your bill for total, including the exclusive, irrevocable right to receive payment for such services, make demand in my name for payment, and prosecute and receive penalties, interest, court cost, or other applicable insurance or state statute. I as the patient and/or responsible party, further agree to cooperate, provide information as needed, and appear as needed, where ever to assist in the prosecution of such claims for benefits upon request.
DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me/us for treatmentrendered by therapist/facility named above, you are hereby tendered demand to pay in full the bill for services rendered by the therapist/facility named above within 60 days following under the terms of my/our policy for benefits, less any 3.62 and 3.62-1 of the (STATE) Insurance Code, providing for attorney fees, 12 Penalty, court cost, and interest from judgment, upon violation.
THIRD PARTY LIABILITY: If Patient(s) treatment for injuries are the result of the negligence of any third party, the patient(s) grant a lien against any recovery from such third party(s) to the extent of the bills for treatment, in favor of the therapist/facility named above.
STATUTE OF LIMITATION: Patients waive the right to claim any Statute of Limitations regarding claims for services rendered or to be rendered by the therapist/facility named above, in addition to reasonable costs of collection, including attorney fees and court costs if incurred.