PIP or L&I Medical Packet

Transcription

1 200 S Tobin St, Ste A Renton, WA PIP or L&I Medical Packet We welcome you to our clinic! Enclosed you will find all the paperwork needed for your first visit. As you are using an insurance claim through PIP or L&I as payment for your sessions, we must have all the required paperwork in order to properly submit billing. New Client Paperwork Client Intake Form PIP or L&I Medical Billing Agreement Activities of Daily Living Assessment Medical Records Release Form Documents you must provide Copy of your driver s license or photo identification Doctor s Referral for massage - This can be a referral, but sometimes it looks like a prescription. It must give a reason (diagnosis) for why you are seeking massage, including ICD-10 codes for this reason/diagnosis. If this paperwork is incomplete, or you do not have your referral at your first appointment, you will be responsible for payment of that session as we cannot submit billing for your claim without that documentation. Please note that insurance companies will not pay for missed appointments, which includes last minute cancellations. You will be responsible for the payment of these sessions, so please make sure to review our cancellation policies before scheduling your appointments. We look forward to helping you on your health journey. If there is anything we can do to help you in this process, please us at billing@goodliferenton.com or by calling Kylee Davis & Amy Gunn Co-Owners, LMTs Teresa Araucto Billing Manager

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4 200 S Tobin St, Ste A Renton, WA PIP or L&I Medical Billing Agreement Date of Injury: PIP L&I Claim # Case Manager/Insurance Agent Name: Case Manager/Insurance Agent Phone Number: Referring Practitioner: Phone: Place of Employment: Supervisor Name: Employer Phone: Social Security Number: Date of Birth: Financial Agreement Details I, (print name), agree to pay the full cost for all sessions not covered by my claim, and/or all sessions that are denied for payment by the insurance company. Any appointments that are cancelled within 24 hours of the appointment time will be charged to my card on file for 50% of the session cost. Any appointments that are cancelled within 4 hours of the appointment time, for which I do not show, will be charged to my card on file for the full session price. Additionally it is my responsibility to schedule only the number of sessions listed on my referral. I will be responsible for the payment of any additional sessions that are scheduled. It is my responsibility to be aware of any remaining coverage through my PIP or L&I claim. Page 1 of 2

5 Medical Billing Agreement (cont.) Lawyers If your claim moves forward as part of a legal case lasting longer than 6 months, we will open a lien on the settlement, and charge 12% interest annually. There will be additional fees, not limited to: Filing fee - city/county/state ~$150 Administrative fee - $50.00 per hour Payment plans: At The Good Life Massage, you can arrange to pay your account balance on a monthly basis. 1% interest will be charged per month on the remaining balance for your account. You can use your Health Savings or Flex Spending account for this purpose. Fees: Here is the list of possible fees that could be added to your account Certified Letter - $75 per certified letter to advise you to pay your bill, not the same thing as a billing statement Records request - From a lawyer or a client, there is a $26 administrative fee with $1.17 per page printed/ ed and sent for the first 30 pages, $0.88 per page printed/ ed for 31+ pages. Records burned to CD - From a lawyer or a client, there is a $26 administrative fee with $1.17 per page printed/ ed and sent for the first 30 pages, $0.88 per page printed/ ed for 31+ pages. Additionally there is a mailing fee of $7.50 Collections: Clients will be turned over to collections for the following reasons, charging your total remaining balance with an additional 12% interest (1% per month/12% annually) and administrative fees: Refusal to respond for information about the claim Refusal to pay on remaining balance Ran out of coverage and they are not paying on their bill at least 10% per month. Signature: Date: Clinic use only: Billing fax number: CMS 1500 Invoice Page 2 of 2

6 0 = No disturbance due to pain/injury L = Light due to pain/injury M = Moderate due to pain/injury S = Severe due to pain/injury

7 200 S Tobin St, Ste A Renton, WA Authorization for Use/Disclosure of Health Information Authoriza on for Use/Disclosure of Informa on : I voluntarily consent to an authorize my healthcare provider (insert name) to use or disclose my health informa on during the term of this Authoriza on to the recipient that I have iden fied below. Recipient : I authorize my healthcare informa on to be released to the following recipient(s): Name: The Good Life Massage PLLC Address: 200 S Tobin St Ste, A Renton, WA Phone: Fax: Purpose : I authorize the release of my health informa on for the following specific purpose:. (Note: at the request of the pa ent is sufficient if the pa ent is ini a ng this Authoriza on) Information to be disclosed : I authorize the release of the following health informa on: (check the applicable box below) All of my health informa on that the provider has in his or her possession, relevant to my injury or claim for massage therapy at this me. Only the following records/types of health informa on:. Term : I understand that this Authoriza on will remain in effect: From the date of this Authoriza on un l the day of, 20. Un l the billing of my claim is completed in its en rety. Page 1 of 2

8 Authorization for Use/Disclosure of Health Information (cont.) Reciprocity : I authorize The Good Life Massage to communicate with the following health care provider, as needed for my con nued care under this claim: Name: Address: Phone: Fax: Signature Date Printed name If Individual is unable to sign this Authoriza on, or is a minor, please complete the informa on below: Signature Date Printed name Rela onship to client Page 2 of 2