MVA/Insurance Billing
Thank you for seeking out medical massage (Mx) and bodywork with Blissful Being Wellness, LLC

Our mission to serve our community with therapeutic and holistic care extends to providing services covered by insurance as much as we are able. 

Please complete the following information so we can begin the process of billing ASAP and best serving YOU :)

VERY IMPORTANT*:
For MVA/WC, you WILL need a referral from a healthcare provider for Massage/Manual Therapy WITH Dx codes.
For Health Insurance Mx, you MAY need a referral from a healthcare provider and must find out from your insurance provider. **ALL referrals MUST be submitted to us prior or on first date of service.
Email *
Full legal name* (First & Last) 
*as appear on your health/auto insurance card(s)
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Birth Date *
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Primary* Health Insurance Plan name, policy number, member number. *If a secondary insurance plan exists, please also include here.

Important: Please email a scanned copy or picture to blissfulbeingwellness@gmail.com
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Why are you requesting medically covered services? *
SECTION 2: MVA/WC
The following questions are specific to Motor vehicle accidents and worker's compensation.
ALL questions are required and if unanswered will delay our progress. 

Please leave blank if this section does not apply to you and move on to SECTION 3: Health insurance Medical Massage & SECTION 4: Scheduling
On what date was your accident?
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What is the claim number for your accident?
What is the name of your auto insurance plan and policy number?
If you know the name and contact of your medical adjuster, please also include. 
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SECTION 3: Medical Massage as part of a health insurance plan
The following questions are specific to Health insurance covered Massage Therapy (Please note, we cannot bill OHP/Medicare/Medicaid insurance plans).

ALL questions are required and if unanswered will delay our progress. We urge you to contact your member benefits representative to help answer unknown questions. Thank you!

Please also complete SECTION 4: Scheduling
Has your annual deductible been met?
Clear selection
Do you have a copay or coinsurance and what are those details?
What is your annual limit for Massage Therapy?
Are you required to have a doctor's referral for massage/manual therapy?
Clear selection
What is your reason for seeking medical massage therapy and how long has your issue persisted?

Thank you, we look forward to helping you soon, almost done!
SECTION 4: Scheduling
THANK YOU so much for all of this information, your time and your confidence in our services. We look forward to working with you soon & now you can get scheduled! FIRST, we require prepayment of first-time services.

ALL new clients are asked to Schedule Online and select "New Client Appointment." This is a 90-minute appointment at $135 which will allow us to go over the intake form together, review goals for treatment, and of course treat! Any cost to you will go towards unmet deductible/copay/or simply to hold for a late cancelation/no show. If your insurance covers the first appointment and other costs are already met, this amount will be refunded to you within 30 days of first insurance reimbursement received (reiterated below).

LINKS:
New Client Intake form (required for first appt; if you cannot print and complete ahead of time, come early): 
https://www.blissfulbeingwellness.com/_files/ugd/ca1e2f_3d98d280f0ff4c56a2c877141c475ff1.pdf
Blissful Being Wellness Policies & Agreements:  https://www.blissfulbeingwellness.com/policies-agreements
Booking first appointment: ALL new clients are required to prepay their first appointment of 90-minutes at $135 

Any cost to you will go towards unmet deductible/copay/or simply to hold for a late cancelation.

If your insurance covers the first appointment and other costs are already met, this amount* (less fees/tip) will be refunded to you within 30 days of first insurance reimbursement received. *There is a 4% fee for credit cards. 

To pay without fee, first complete this form and send us an email to notify prepayment via Zelle: blissfulbeingwellness@gmail.com or Venmo @blissfulbeingwellness
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In choosing to work with us, you agree to have read and will comply with our Policies and Agreements. *
Is there anything you wish to share with us at this time? *
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