4206 Stone Way North, Seattle, WA 98103
Confidential Client Intake Form
Massage History/Treatment Information:
*Have you had a professional massage? Yes No
If yes when was the last one?
What brings you in today?
Are there specific areas of your body you want to focus on for today’s massage?
Informed Consent to Massage
- I understand that the massage given to me is for the purpose of stress reduction, pain reduction, relief from muscle tension, increasing circulation, or specific reasons stated on my prescription.
- I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy.
- I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have.
- I have stated all my known physical conditions, and I will keep the massage therapist updated on any changes.
Client or Parent/Guardian Signature:
- Patient Financial Agreement
- We require and appreciate a minimum of (24) hour notice.
- A fee of $50 will be charged if (24) hour notice is not given.
Payment for visit, co-pays (if using insurance) is to be rendered at time of service and can be made by cash, check, debit or credit card.
- Adding a gratuity to your charges is allowed and is optional.
- There is a $35 NSF fee on all returned checks.
In order to bill insurance, you must provide the following at your first visit:
- Patients using insurance are responsible for confirming their insurance massage benefits and the amount of your co-pay with your insurance company prior to your first visit. Aditi will not verify benefits.
- Prescription from your health care provider, regardless if your insurance plan says they do not require a prescription we will need one for diagnostic code and length of visits prescribed.
- Insurance card.
- Credit card to keep on file for any insurance outstanding balances.
Patients using insurance will be held accountable for non-payment by their insurance company. Accounts unpaid by the insurance company greater than 90 days will be billed to the patient. Outstanding balances greater than 120 days will be turned over to a collection agency.
What method of payment are you using for your massage (Cash/Credit/Debit/HSA/Gift Card/Insurance)?
I, , agree to the above defined financial policies of Aditi. In the case of default of payment, I am responsible for full payment of the balance, interest accrued, and any collection costs and legal fees incurred to collect on this account.
I, the undersigned, have read, understand, and accept the information and conditions specified in this document.
Client or Parent/Guardian Signature:
Review of Symptoms: (Check any of the following you have or have had in the past 6 months.)
Have you had any conditions, (not listed above), that you think your therapist should be aware of?
List any previous injuries/accidents or surgeries you have had in the last 5 years.
*Are you currently on any medications? Yes No
If yes, please list.
Please mark on the body drawing where you are experiencing pain or discomfort.
4206 Stone Way North, Seattle, WA 98103
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on today's date, and will remain in effect until it is amended or replaced by us.
It is our right to change our privacy practices provided law permits the changes. Before we make a significant change. this Notice will be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes In our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made.
You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer, Julie Morse. Information on contacting us can be found at the end of this Notice.
TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION
We will keep your health information confidential, using it only for the following purposes:
Treatment: We may use your health Information to provide you with our professional services. We have established 'minimum necessary or need to know" standards that limit various staff members' access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.
Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health Information about you may also be disclosed to your family, friends and/or other persons you choose to Involve in your care, only if you agree that we may do so. We will always inform you if your protected health information is breached. You have the right to receive non routine disclosures we have made of your health care information.
Payment: We may use and disclose your health Information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved In the process of malting statements and/or collecting unpaid balances.
Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death. If at all possible we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise.
Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities.
Required by Law: We may use or disclose your health information when we are required to do so by law (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an Inmate or otherwise under the custody of law enforcement.
Abuse or Neglect: We may disclose your health Information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.
Public Health Responsibilities: We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.
Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so.
National Security: The health Information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. if the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders. including, but not limited to, voicemail messages, emaits, postcards or letters.
YOUR PRIVACY RIGHTS AS OUR PATIENT
Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. Copies, if requested, will be S (.50) for each 10 pages and the staff time charged will be $ (none) per hour including the time required to locate and copy your health information If you want the copies mailed to you, postage will also be charged. If you prefer a summary or an explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure.
Amendment: You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.
Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We do not have to agree to these additional restrictions, but if we do, we will abide by our agreement. (Except in cmcrornrion ) Picric() rnntnrt nur Privncy Clffirnr if you want to further restrict afICAF.s to your health care information. This request must be submitted in writing.
QUESTIONS AND COMPLAINTS
You have the right to file a complaint with us If you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us. Request a Complaint Form in writing from our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
HOW TO CONTACT US
Practice Name: Aditi, LLC
Privacy Officer: Julie Morse
Address: 4206 Stone Way North, Seattle, WA 98103
HIPAA Notice of Privacy Practices
This form does not constitute legal advice and covers only federal, not state, law
C/My documents/ECIM/Forms/HIPPA/Notice of Privacy practice