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Insurance Work at OZssage Spa
We do submit Auto Insurance and Workers compensation once approved by your insurance company. Please submit the following form and we will be back in contact to set up your appointments,.
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Contact Information
Full Name
*
Your answer
Phone number
*
Your answer
Email address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Date of Injury
*
MM
/
DD
/
YYYY
Insurance Information
Type of Insurance
*
Auto Insurance
Car Insurance
Which company do you work for - this is for workers only
Your answer
Insurance Company:
*
Your answer
Claim Representative:
*
Your answer
Claim representative phone number & fax if known
*
Your answer
Group or Policy #
Your answer
Claim or Case #
*
Your answer
Referring Physician
You must have a doctors referral. On that referral the doctor must state what is wrong and the MEDICAL CODES and how many times to be treated
Who is your physician
*
Your answer
Do you have a doctors certificate with codes - please email to
info@ozssage.com
*
yes
no
Other:
First Booking
Please state day and time you would like for your first booking - please give us options if you can
Days
*
flexible
Other:
Time of booking
flexible
Other:
Clear selection
Cancellation Policy
Please understand that the therapists time has been reserved for you. Please respect our 24 hour cancellation policy for any changes and cancellations. This will not be covered by your insurance company so when you book your first appointment you will be required to provide a credit card to be charged in the case of no show.
Thank you
Yes I have read and understand the cancellation policy
*
yes
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