Insurance Verification Form

We are happy to bill your Medical Insurance (Regence Blue Cross Blue Shield, American Specialty Health, Tri-West, UHC, etc), Worker’s Compensation Insurance or Motor Vehicle Accident Insurance. It’s always a good idea to call your insurance company to see what will be covered and if you need a doctor’s referral or prescription.

Here is helpful information on how to be sure that your insurance company will pay for your massage therapy.

Please fill out the form below as best you can so we may verify your insurance coverage.

Name

First Name

Last Name

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

Address (Please Include City, State, and Zip Code)

Date of Birth

Health Insurance Company Name

Group #

Patient Policy ID #

Name of Insured (Subscriber Name)

Birth Date of Insured (if other than you)

Relationship to Insured (Ex: Spouse or Parent. If self, leave blank )

Do you already have a doctor's referral or prescription for massage therapy?

Yes

My Policy Does Not Require a Referral or Prescription

Name of Referring Provider (Doctor or Other)

Title of Referring Provider (Doctor or Other)

Office Name and Phone # of Referring Provider (Doctor or Other)

The Section Below Applies to Motor Vehicle Accident and Workman's Compensation Insurance Claims

Primary (Your) Auto Insurance Company

For Motor Vehicle Accident Billing Only

Secondary Auto Insurance Company Involved in Your Claim

For Motor Vehicle Accident Billing Only

Date of Motor Vehicle Accident

For Motor Vehicle Accident Billing Only

State Where Motor Vehicle Accident Occurred

For Motor Vehicle Accident Billing Only

Is this related to Worker's Compensation?

Yes

Dates of Missed Work

For Worker's Compensation Only

I understand and agree to the following:

Health Insurance often covers massage therapy, but coverage varies. Some plans require a doctor’s referral, while others allow visits without one. Coverage can range from full payment to requiring a co-payment. Luna Healing Massage recommends contacting your insurance company before your first appointment to confirm therapy services. It is important to understand what services are covered and what you are responsible for paying out of pocket. I am ultimately responsible for the cost of my care, regardless of what happens with my insurance claim. If Luna Healing Massage has not received my insurance verification prior to my scheduled appointment, I will be charged in full at the time of my appointment and Luna Healing Massage will reimburse me the session fee minus my copay once they have received my coverage verification.

Yes, I Understand and Agree

No, I do not agree and will instead opt to pay out-of-pocket. Please do not bill my insurance.

Insurance Verification Form

Contact Us for More Info: