Authorization Form

Please Fill Out Form

Authorization to Bill Insurance Form

Name

Guardian Name (If minor)

Date of Birth

Policy Number

Phone Number

Address

I, the undersigned, hereby certify and attest that I have sought medical massage treatment(s) from the staff of Massagical Hands LLC. I, therefore authorize the medical staff and personnel to release my or my minor child's medical information to the insurance company listed above for the purpose of determining and receiving benefits for medical massage(s)

I understand and acknowledge that the medical staff will submit my claim(s) to the insurance company on my behalf. I further understand that I am responsible for my Co-Insurance payments.

Date Signed

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