Insurance Verification Form

Casey Gates Rolfing
5105 SE Hawthorne Blvd
Portland, Or 97214
www.caseygatesrolfing.com
caseygatesrolfing@gmail.com
(971) 413-3106

Section 1 - Personal Information
Name *
Name
Home Address *
Home Address
Date of Birth *
Date of Birth
Phone # *
Phone #
Section 2 - Personal Health Insurance
If you are interested in using your health insurance to pay for services fill out this section
Section 3 - Motor Vehicle Accident or Workmans Comp Only
If this is a Motor Vehicle accident claim or Workmans Comp Claim fill out this section
Date of Accident
Date of Accident
Name of insured if other than yourself
Name of insured if other than yourself
Section 4 - OFFICE USE ONLY
PLEASE LEAVE THIS SECTION BLANK - SCROLL DOWN TO THE BOTTOM AND CLICK SUBMIT AFTER YOU HAVE FILLED OUT THE APPROPRIATE SECTIONS.
Is the provider in network?
Is the client covered for Massage by an LMT?
Does the client need a prescription or referral for massage?
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