Personal Injury Protection Screener (PIP)

Personal Injury Protection (PIP)

Intake Screening & Consent to pursue PIP insurance coverage, treatment, and billing
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Can we call you and leave a detailed voicemail message if necessary?*

YesNo
Date of Birth*

MonthDayYear
Date
Gender Identity*

MaleFemaleNon-Binary
Name of doctor or chiropractor who provided massage referral*
Is your coverage through a 3rd party? (Meaning you are seeking treatment and will be covered by the other parties insurance coverage.)*

NoYes-Please be aware that we do not bill 3rd party insurance and you will be required to pay for treatment out of pocket for each session
Name of Auto Insurance Company:*
Auto Insurance Policy Number:*
Name AND phone number of Claim Adjuster or Case Manager:*
Claim or Case Number:*
Date of injury and state where accident occurred:*
Name AND phone number of attorney (if applicable):
You are required to have a prescription for massage treatment from your doctor or chiropractor. The prescription MUST include a diagnosis and number of treatment sessions prescribed. You are REQUIRED to provide this. Do you have this and does it include the required information?*
Please describe the general injuries you sustained in the auto accident (you will complete a very detailed form during the intake process):*
Areas of current pain, sustained injury, and concern:*

NeckUpper BackLower BackShouldersHandsLegsFeetLimited MobilityMuscle TightnessSciaticaNumbness/TinglingArthritisBursitisTendonitisPoor PostureLeg InjuryArm InjuryMajor Back InjuryHead InjuryNeck InjuryOther-will share with therapist
Anything else you'd like us to know?
All of the information you provide to Bloom & Blossom Wellness Center must be true to the best of your knowledge. Auto insurance policies are an arrangement between you and your insurance carrier. This office will send claim forms to your insurance carrier for payment of services which will be directly paid to Bloom & Blossom Wellness Center. Your signature indicates authorization for payment of any insurance benefits directly to Bloom & Blossom Wellness Center. All payments received will be directly credited to your account. You are responsible for any and all charges that your insurance does not pay. You agree to pay any collection or attorney fees that should arise from nonpayment. If you suspend or terminate care and treatment, any fees for professional services rendered will be immediately due.

You are required to have a valid credit card on file. If you cancel your massage appointment within 24 hours of your scheduled appointment time or do not attend your scheduled appointment, you will be charged a fee of $95. This fee is not covered by your insurance and must be paid by you. If you are more than 20 minutes late to your scheduled appointment, you will be asked to reschedule and will be charged $95. If you miss the start of your appointment due to being late, your therapist will not add extra time to your treatment. Exceptions to late cancellation fees include emergency and inclement weather and must be communicated immediately via phone call to our office. If you miss two consecutive appointments, you will not be allowed to schedule any future appointments and any balance will be due immediately.

Your signature indicates that you agree to the terms above.
Signature*

Clear
Bloom & Blossom Wellness Center utilizes the following protocol for PIP insurance and treatment:

1. Patient completes the intake screening and consent form.

2. Our treatment coordinator reviews the information in full. The insurance claim adjuster or case manager will be contacted to verify coverage and gather relevant information.

3. If the patient requires a treatment that our medical professionals are not able to provide, we will inform the patient of this.

4. After all relevant information is gathered and verified, the patient is contacted via phone or email for scheduling.

5. The patient is required to provide all documentation and insurance information prior to the first appointment.

Your signature indicates that you understand the scheduling and verification protocol. Completion of this form does not gaurantee you will receive treatment at our facility.
Signature*

Clear
Your signature below provides your consent for our treatment coordinator to contact your insurance adjuster, legal representative, referring physician, and other medical providers you have identified on this intake form to release your medical records and information related to your injury claim. We agree to follow HIPAA guidelines and regulations regarding your Protected Health Information (PHI).
Signature*

Clear
Today's Date:*

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Date
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Personal Injury Protection (PIP)