Clinical Massage Therapy Insurance Benefits Verification Form

If you’d like to be treated by Hayk and you’d like us to bill your insurance, please fill out this massage benefits insurance verification so we can find out for you if your insurance company pays for therapeutic massage therapy.

Be advised that your information is handled though top of the line secure electronic service providers, it’s safe and it will never be shared with anyone.

By submitting the Massage Therapy Insurance Benefits Verification Form you agree for us to contact your insurance provider on your behalf to verify your massage and manual therapy benefits.

Patient's Name

First Name

Last Name

Patient's Date of Birth

Patient's Home Address

Patient's Phone Number

Patient's Email

What symptoms are you experiencing? What are the conditions, injuries, and painful areas you’d like to treat with our clinical services?

Please start with the chronic issue. 1. Where does it hurt? 2. For how long have you had this problem? 3. On a scale of pain 1-10, how much pain are you in? (1 = Discomfort, 10 = Severe Pain) 4. Does the pain radiate down arm/leg? 5. Were there any diagnostic tests performed?

Your Doctor's Name and Contact Information

Do you have a doctor's prescription for this condition? If yes, what is the prescription for exactly?

Insurance Company Name

Insurance ID Number

Insurance Group Number

Insurance Company Phone Number for Provider

The Primary Insurance Policy Holder's Name

The Primary Insurance Policy Holder's Relationship To Patient?

If you have any questions call us at (732)766-0897 or email at hi@zar.ink