Motor Vehicle Personal Injury, Massage Insurance coverage questionnaire Where you in a motor vehicle accident within the last 12 months? * Yes Please provide the date you experienced this auto accident * MM DD YYYY At the time of the accident, was a police report made, and the incident reported to the auto insurance providers? * A police report is required for your insurance to cover bills related to the personal injury treatment Yes A police report was made. It was not reported to insurance but can be if it will get me treatment. Was either driver carrying auto insurance as a resident here in the state of Oregon? * In the state of Oregon, 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 the car I was in did have auto insurance at the time & the car was registered in Oregon Yes, the car I was in had auto insurance and was registered in Oregon Yes, the other automobile had insurance and was an Oregon registered vehicle 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 by an auto insurance policy. 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 get set up for insurance covered massage therapy. 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 booking a massage? * Be aware that cancelation policy charges are not covered under insurance: 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 will be required for booking services * No problem... happily Where did you hear about Holistic Healing Harbour? * Business card Google search Yelp NextDoor Referral Safari While driving Other Thank you! You should be hearing from us soon.
