Office Policies Agreement

Please fill out the below Office Policies Agreement. If you do not wish to fill out the form online, you can may download a PDF copy here which can be filled out and printed. Please bring the completely filled out form to your first appointment with us.

  • Please be advised of the policies for this office. Your signature below signifies acceptance of these policies.
    A 24-hour notice is required for cancellation of an appointment, or you will be charged in full for the appointment. Payment is due before your next appointment.

    Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. Please be on time to your appointment.

    Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived.

    If this office is providing billing services, please be advised of our billing policies.
    We do not bill insurance companies for missed appointments or late cancellations. You are responsible for paying the missed appointment/late cancellation fees.

    Financial Responsibility
    Once your insurance is verified, we will bill and accept payment from your insurance company for covered services. In the event that the insurance company denies payment or makes partial payment, you are responsible for the balance, deductibles, and co-pays. Your signature below confirms your financial responsibility for all services regardless of insurance reimbursement.

    Assignment of Benefits
    Your signature below authorizes and directs payment of medical benefits to the massage/bodywork practitioner for services provided by this office.

    Release of Medical Records
    Your signature below authorizes the release of all of your medical records on file in this office, for the purpose of processing your claims, to the following: your attorney, the healthcare providers attending to this condition, and the insurance case managers. Medical records will not be edited unless otherwise stated in an exclusive release of medical records signed through your attorney.
  • By electronically signing this form, you are agreeing to the terms of our office policies stated above.