Work Comp Intake Form
(Version 7/31/24)
Authorization to pay provider
My signature below authorizes payment of medical benefits to the Big Island Massage
Network for any services furnished to me.
Medical Records Release
My signature below authorizes Big Island Massage Network to release to my insurance
company, consulting physician, and collaborating practitioners and their administrative staff
information concerning health care, advice, and treatment. This information will be used for
treatment, payment, and operations.
Financial Responsibility
If I book a treatment that is outside of what is specified in my treatment plan (sessions per
week, total number of sessions, effective dates, or area of my body to be treated) I
acknowledge that such a treatment is not part of my work comp claim and I commit to paying
for this treatment myself within 30 days of the date of service. I need to pay especially close
attention if I am working with more than one therapist at a time because they will not
necessarily know what treatments other therapists in the network have performed.
Signature below applies to all items on this page
Jessica Knight
Printed Name: _____________________________________ Date: 08/06/2024
_______________
Signed: _____________________________________
Jessica Knight (Aug 6, 2024 00:22 HST)
Cancellations, No-Shows, and Late Arrivals
(v 2023 03 17)
Our massage therapists have full schedules and when someone doesn’t show up or cancels with short notice
the therapist usually cannot make up that lost income. So even though you might have the best reason in the
world, no ill intention or neglect, a short notice cancellation still has a negative financial impact on the therapist.
Signing this policy is your agreement to share the burden. The therapist always has the option to waive a fee if
appropriate and in general the more considerate you are, the more room there will be for flexibility.
• Zero tolerance for No Shows and Ghosting
• Big Island Massage Network reserves the right to discontinue treatment for any reason including
violations of this policy
• Massage therapist has the authority to waive any fee they feel appropriate depending on the
circumstances.
• This agreement applies across all offices in the Big Island Massage Network unless a particular office
has you sign their own policy.
_____ Cancellations with less that 24 hours notice will be charged a $25 fee, due before the client continues
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(initial) treatments.
_____ No-shows with no call or response may result in termination of care. In some cases, when allowed,
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(initial) the therapist may accept a $50 fee to resume treatment.
_____ Contact therapist directly for any cancellations or changes. The BIMN administrative office does not
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(initial) handle scheduling.
_____ Late arrival will often mean a shorter session. Try to arrive 5 minutes early to be settled and ready to
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(initial) start on time.
_____ Late arrival more that 15 minutes without notifying massage therapist is considered a no-show and
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(initial) the therapist may leave the office.
_____ Client is responsible to know how to get to the massage therapist. Do not rely on texts or calls to the
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(initial) massage therapist on short notice, they are likely busy with a client and will not be able to answer. If it
is your first time, go early to give yourself plenty of time to find the place. Some of our offices are in rural
areas with no cell phone coverage, plan accordingly.
Jessica Knight
Printed Name: _____________________________________ Date: 08/06/2024
_______________
Signed: _____________________________________
Jessica Knight (Aug 6, 2024 00:22 HST)
If client is under 18 years, signature is by fiscally responsible parent or guardian
____________________ _____________
Guardian Printed Name Guardian Relationship
