No-Fault Accident and Workers Compensation: Information Form
***Please call first to check availability*** This form will provide the necessary information needed to schedule a massage covered by PIP auto insurance or Workers' Comp after an automobile or job-related injury has occurred. Please be aware that this information is not encrypted and will be transmitted over the internet. You can also provide your information by phone, if preferred. Call Integrated Massage and Deep Tissue Therapy at 808-285-3009
Your full name *
Your answer
What kind of claim do you have? *
Mailing address *
Your answer
E-mail address *
Your answer
Phone *
Your answer
Date of Birth (Month/Day/Year) *
Your answer
Insurance company *
Your answer
Insurance address *
Your answer
Claim representative *
Your answer
Phone number and extension of representative *
Your answer
Date of injury (Month/day/year) *
Your answer
Claim or case number *
Your answer
Prescription details: physician's name, ICD-10 diagnosis code, and duration/frequency of massage *
Your answer
Is your prescription specifically for massage therapy (97124)? *
Your answer
PIP policy maximum or maximum allowance (example: $10,000) *Answer N/A for Worker's Comp claims* *
Your answer
Approx. PIP or Insurance coverage currently available (example: $8,000) *Answer N/A for Worker's Comp claims* *
Your answer
What is your PIP deductible and has it been met? (example: $1000, NO) *Answer N/A for Worker's Comp claims* *
Your answer
Maximum number of massages allowed for your condition? *
Your answer
How many massages have you already received for this particular injury? *
Your answer
Briefly describe your injury and its effects *
Your answer
Did your injury require an ER visit? What specialists have you seen? What treatment is recommended? *
Your answer
At your first appointment, your credit card information will be taken. You will be charged in accordance with your insurance deductible and also charged for any amount that exceeds your PIP/ insurance maximum allowance. You may also be charged according to our cancellation policy when applicable. Mahalo for your interest in our clinic. We look forward to helping you achieve your goals. Please bring your prescription for massage (written by a medical doctor) and any additional paperwork to your appointment. *
Required
Additional Information: What else would you like us to know?
Your answer
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