PAPER SUBMISSION FORMS: Print and fill out these forms to speed up the intake process during your first visit.
- Acupuncture Health Intake for Pain Management 2018 – Orthopedic Acupuncture (best to use for billing insurance)
- LNI Acupuncture Health Intake for Back Pain 2018
- Massage Therapy Health Intake with Agreements 2018
- MVA Health Intake Massage Acupuncture with Agreements 2018
ONLINE SUBMISSION OF MASSAGE THERAPY FORM:
- Online Massage Therapy Intake Option – if you do not want to deal with paper.
- If your using your insurance, PIP, or have an L&I Claim, please fill out the Insurance Verification Form as well.
REFERRAL FORMS AVAILABLE FOR PRIMARY CARE PROVIDERS:
Prescriptions with treatment plans for Massage Therapy are required for all HMA and Regence patients for plans that require authorization.
The following referral forms are available for referring providers. Primary care providers may be Physicians, Chiropractors,
Naturopathic physicians, Podiatric physicians, Advanced registered nurse practitioners, Physician assistants, Dentists, and Optometrists. Please check with your insurance plan to confirm who is accepted as a referring provider.
- Massage Therapy Medical Prescription, Referral, Med. Necessity 2018
- LNI Acupuncture Health Intake for Lower Back Pain 2018
Other forms/informational material of interest:
- New Patient Registration ia
- Authorize to Disclose Form
- Notice of Privacy Practices
- Patients Rights and Responsibilities
- What is Cupping Massage Therapy
- Informational Cupping Massage Therapy Brochure
- VIDEO: The Science of Acupuncture BBC Documentary