Consent FormHealth Intake FormInsurance Info FormSOAP Chart

  •  Premera Blue Cross
  •  LifeWise
  •  Uniform Medical Plan (UMP)
  •  Reliant - Pacific Source
  •  Corvel
  •  CIGNA Health Care
  •  Aetna US Healthcare
  •  First Choice

  •  Workman's Comp (L&I)
  •  PIP -- Personal Injury Protection (Auto Accidents)
If your insurance isn't listed, please send me an email and let me know which insurance you would like me to accept to bill for
your massage visit.
The following documentation is REQUIRED for the CMS-1500 insurance form we are required to submit If you
plan to bill insurance for your massage visit :

  •  Insurance ID card
  •  Co-payment (If your insurance carrier requires)
  •  Prescription for massage from Physician, Chiropractor, or Physical Therapist   
  •  (Must Have Start Date, Frequency, Duration, Verbal Diagnosis, Diagnosis ICD-9 Code)

Client/Patient will be required to self pay for the visit if above information is not provided at the time of
service or pay a cancellation fee of $50 if unable to provide required info above.
Re-Leaf Massage
Relax / Renew / Realign
My Insurance company doesn't require a referral so do I need to bring a prescription?

Yes, Re-Leaf requires both a prescription and diagnosis code (this is a numeric code in addition to a
written verbal diagnosis).  

The reason for these requirements are two fold.  First prescription for massage is similar to a
prescription for a pharmacist.  We want to ensure we are treating the specific issue your Physician,
Chiropractor or Physical Therapist had in mind.  Because there are many numerical codes for each
verbal diagnosis, and to ensure we treat and bill your diagnosis appropriately it is necessary
requirement that we receive both a verbal (written) prescription and diagnosis code from your
prescribing health care provider to ensure we bill your treatment appropriately.  

Without the proper code your diagnosis could be billed to your insurance company incorrectly and
possible create an insurance inquiry, which in turn could also cause your claim to be unnecessarily
denied and unclaimable, which would leave you financially responsible for any and all billings.
Health Insurances Accepted:





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changes will be charged $50.
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Re-Leaf Massage
While medical insurance billing may seem simple from a client perspective, it is
a constantly changing, complex industry.  We have found the best practice is
to acquire all required documentation upfront avoiding unnecessary confusion
or an insurance inquiry - this could cause a claim to be denied, leaving the
client financially responsible for all massage billings both current and future.
Please review the documentation that is required for the CMS-1500 insurance
form, prior to booking your appointment.  Req'd docs are listed below.