Auto Accident and Insurance Information Claim

Seattle Massage Pro

Phone: (206) 909-2994

Fax: (206) 922-2053

Claim #:

PIP InsuranceClaims Information

To ensure verification of coverage before treatment begins, please fill out the information below and return it along with a written referral from a doctor to Amber Myers of Seattle Massage Pro before your first appointment. Payment is due in full if the form is not returned 24 hours before the appointment. This amount will be either refunded or applied to your copayment balance after verification. Thank you for your cooperation in promptly verifying your coverage.

Client Information

Last name: / First name: / Middle initial:
Address:
Primary phone: / Email: / Date of birth:
Emergency contact: / Emergency contact phone:
Employed Full-time student Part-time student / M F / Single Married
Condition/injury:
Referring Dr: / Facility:
Dr address: / Dr. phone:

Auto Accident and Insurance Information Claim #

Date of Accident: / Location (state) of accident:
Insurance company representing you: / Member ID:
Insured’s address (if not your policy):
Adjustor name: / Adjustor phone:
Were you at fault? yes no / Name of at fault:
Address of at fault:
Insurance company of at fault: / Member ID:
PIP policy amount: / Dates of coverage: / PIP available:
MedPay amount: / Dates of coverage: / MedPay available:
Liability policy amount: / Dates of coverage: / Liability available:

Authorization, Payment Agreement, and Release of Records

My signature below authorizes and directs payment of medical benefits for services billed to Seattle Massage Pro. I understand that I am responsible for any amount not paid by my insurance and will pay promptly. I authorize the release of my medical information to my medical providers, attorney’s, and insurance case managers necessary to process my claims. I will also inform my practitioner immediately upon signing any exclusive Release of Medical Records with my attorney.

Client Signature: ______Date: ______