Massage Intake Therapy

Save time and fill out your intake form before your appointment! Please fill out the form below. Items marked with an asterisk are required when submitting.

Patient Information

Today's Date*

First Name*

Last Name*

Home Address*

City*

State*

Zip*

Date of Birth*

Gender
FemaleMale

Occupation

Cell Phone*

Home Phone

Work Phone

Email Address*

Emergency Contact and Phone

Contact Preference
Home Cell Email Work Mail

Referring Physician

Secondary Physician

Insurance

If client / patient is going through insurance.

Primary Insurance Company Name

Authorization and Assignment-Insurance
I hereby authorize my insurance carrier to make benefit payments directly to Just Be Fit, Inc/Coronis Health., on my behalf. I hereby acknowledge my financial responsibility for fees not paid by this assignment and agree to pay for any collection and/or legal fees incurred if my account becomes delinquent.

Signature:
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Acknowledgment of Receipt of Just Be Fit, Inc & Just Be Fit, Inc.'s Financial Policies

FINANCIAL POLICY: Just Be Fit, Inc has contracts with many insurance plans. Due to the numerous healthcare plans available, it is the patient's responsibility to verify that we are in network with your specific insurance plan.

Insurance Benefits:
All patients are required to know their Physical Therapy benefits. As a courtesy Just Be Fit, Inc, will call to verify, however, this is not a guarantee of benefits or payment. What the company tells us can be denied or changed during and after the payment cycle. You are responsible for all denied claims. I understand that I am responsible to giving Just Be Fit, Inc any change of information with my insurance coverage. I authorize my insurer to pay any benefits for services rendered directly to Just Be Fit, Inc. I understand that anything not covered by insurance is my full responsibility.

I understand and agree that I am financially responsible for all charges for any service rendered, including late cancellation fees as described in the Treatment Guidelines within Just Be Fit Physical Therapy consent for treatment.
Initials:*

I understand and agree that while my insurance may confirm my benefits, confirmation of benefits is NOT a guarantee of payment and that I am responsible for any unpaid balance.
Initials:*

I understand and agree that it is my responsibility to know if my insurance has a deductible, co-payment, co-insurance, out-of-pocket, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for services I receive and agree to be financially responsible for all.
Initials:*

I understand and agree that if my insurance requires a referral from my primary care physician, it is my responsibility to obtain the referral. Without a referral, my insurance will not pay for any services and I will be responsible for payment.
Initials:*

I understand and agree that it is my responsibility to inform Just Be Fit, Inc. Physical Therapy in case of any changes to my insurance coverage prior to my next appointment. Claims denied due to submission to an expired insurance plan may be denied and will become my responsibility.
Initials:*

I understand and agree that if my account balance is over $300, I will be required to pay the balance in full or initiate a payment plan before additional appointments at Just Be Fit, Inc. Physical Therapy can be scheduled or before I may be seen for my next appointment.
Initials:*

I understand that unpaid balances that are more than 90 days late may be turned over to a collection agency. If my account is turned over to a collection agency, I will be responsible for an additional 33.33% of the unpaid balance to the account for the collection agency service expenses. I further agree to pay reasonable administrative fees, attorney fees, and cover cost arising out of any litigation concerning the collection of this account or any other fees deemed necessary.
If we contract with your plan, we will file a claim (for physical therapy services) to your insurance company. You will be responsible for any co-pays, deductibles, purchased products, and/or non-covered services. If you do not have one of the plans with which the practice is contracted, the total cost of your visit is required at the time of your service.
Initials:*

* It is your responsibility to provide Just Be Fit, Inc with your current insurance information. Failure to do so may result in charges being billed directly to you.
* Any service that is not covered by your insurance company, for whatever reasons, is your financial responsibility. Any outstanding balances over 90 days will be charged to your credit card. If applicable a 3% late fee will be accessed to balances over 90 days and/or patient will be sent to our collection agency.

By signing this form, I acknowledge that I understand and agree with ALL of the above, and that I accept responsibility for charges incurred for treatment or assessment at Just Be Fit, Physical Therapy, regardless of any other arrangements with third parties, including insurers. This for will remain in effect throughout the entirety of treatment with Just Be Fit, Physical Therapy until one year of signature. I agree to pay the fees outlined in this policy.

Patient/Guardian Signature:
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Signature of Person Responsible for Payment (if different from Patient)
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Massage Intake Form

Massage Intake Therapy

Patient Information

Medical History

Insurance

Acknowledgment of Receipt of Just Be Fit, Inc & Just Be Fit, Inc.'s Financial Policies