If you would like to have copies of your files for any reason or your legal representative requires a copy of your files, please download and fill out this form and bring it to your next appointment or submit it to me via e-mail. Written consent for your personal access is not mandatory, however it is mandatory for insurance audits, legal purposes or any other non-personal, third-party use.
If your insurance provider is requesting verification of claims submitted, you will be required to fill out this form to indicate you have given consent before your information is released.
A printing fee of 25 cents per page will be charged for copies.
If you require a medical or progress report of your treatments, a fee of $100/hour will apply (prorated where applicable).
Consent to Release Information Form
If your insurance plan requires a medical prescription or note from your doctor, you can download and print a requisition form and bring it to your next doctor's appointment to be filled out. Please bring the completed form to your next massage therapy treatment and keep a copy for your records.
Please note that a doctor's note is not a guarantee that your insurance claim will be accepted. It is your responsibility to understand your benefits coverage and any limitations or requirements.
