Gig Harbor, WA (206) 713-7169

Forms

 Print and complete your forms at home or arrive 15 minutes early so you don’t lose table time.

COVID-19 Health Consent (ALL CLIENTS)

HEALING & RELAXATION (CASH-BASED)

INJURY TREATMENT (INSURANCE-BASED)

Healthcare Insurance Accepted:  Aetna, BlueCross BlueShield (not Boeing), First Choice, Premera, and Kaiser Options/PPO and a doctor referral for massage. (Only Terri Rossi, LMT, takes Healthcare Insurance patients.)

Motor Vehicle Accidents: Need Personal Injury Protection (PIP) policy and a doctor referral for massage. (Terri Rossi, LMT, and Ramona Dickson, LMT, take PIP patients.)
Injured Worker (L&I) or Crime Victim: Need APPROVED claim and a doctor referral for massage. (Terri Rossi, LMT, and Ramona Dickson, LMT, take L&I patients.)

If using Healthcare Insurance, YOU must call your plan in advance to verify benefits, annual deductible, co-insurance and/or office co-pay. We do NOT do this for you. You will need to:

  • Verify that you have Massage benefits from a massage therapist (some Premera plans cover massage only from a chiropractor or PT).
  • Verify remaining Annual Deductible – what you must pay BEFORE insurance starts to pay.
  • Verify Co-Insurance – what you pay when insurance pays less than 100%.
  • Verify Office Co-Pay – what you pay for each massage session.
ALL plans require your doctor’s diagnosis of your problems and the areas authorized for treatment. Most plans require this information to be written on a referral.