Motor Vehicle Personal Injury, Massage Insurance coverage questionnaire Where you in a motor vehicle accident within the last 12 months? * Yes To the best of your recollection, please indicate the date of injury/accident * It is ok if this is not exact MM DD YYYY Was a police report made regarding the auto accident? * Yes No Did either driver involved in the accident have current and active car insurance at the time? * In the state of Oregon and many other states, auto accident injury treatment along with coverage for lost wages, is included in your policy, regardless of who was at fault. It was a hit and run, but yes the driver had active coverage in Oregon at the time Yes, the car I was in or other vehicle had active coverage in Oregon Neither party resided in Oregon at that time, however, the USA based auto insurance involved, did include PIP (this is required by many states, so you may wish to check the policy) Are you currently seeing a provider in relation to the accident? * A doctor, chiropractor or specialist (a prescribing provider) A massage therapist, a physical therapist or acupuncturist (a non-prescribing provider) Other None If you have been able to make a selection for each of the questions above, then with a prescription we should be able to get your massage treatments 100% covered. HHH partners with a chiropractor in SW Portland, experienced with auto accident recovery, and billing insurance for your comprehensive care. Please take a moment to fill out the rest of this form if you wish to be contacted for next steps. Name * First Name Last Name Email * Phone * (###) ### #### Do you have a general time of day or the week that works for your availability? * It is helpful to know if morning, afternoon, or evenings work best. Do you agree to the no-show and cancelation policy of working with Holistic Healing Harbour? * Cancelation under 24 hours notice are charged 50% the cost of booked service No-Shows are charged 100% the cost of booked services Absolutely. I am accountable to my commitments and respect time put aside for me A credit card on file may be required for booking services * No problem... happily Where did you hear about Holistic Healing Harbour? * Business card Google search Yelp NextDoor Referral Safari Other Thank you! You should be hearing from us soon.
