New Client Welcome Packet
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- Megan Rose
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1 200 S Tobin St, Ste A Renton, WA New Client Welcome 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 Insurance Waiver & Informa on Ac vi es of Daily Living Assessment Medical Records Release Form Documents you must provide Doctor s Referral massage - This can be a referral, but some mes it looks like a prescrip on. 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 documenta on. Please note that insurance companies will not pay for missed appointments, which includes last minute cancella ons. You will be responsible for the payment of these sessions, so please make sure to review our cancella on 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 support@goodliferenton.com or by calling Kylee Davis & Amy Gunn Co-Owners, LMTs Tom Gunn Billing Coordinator Page 1 of 1
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5 Activities of Daily Living Assessment Please assess how your pain or injury affects the following activities by rating them. Use the charts below to track your activities. Date: Name: 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 Activity This Past week Activity This Past week Sleeping Personal Care Driving Car Standing for long periods Ability to exercise Other (specify): Work Recreation Other (specify): Lifting Heavy objects Walking [Type here]
6 200 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
7 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
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200 S Tobin St, Ste A Renton, WA 98058 425-243-7705 www.goodliferenton.com PIP or L&I Medical Packet We welcome you to our clinic! Enclosed you will find all the paperwork needed for your first visit.
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