Assignment of Benefits and Authorization to Release Medical Information.  I hereby certify that the insurance information I have provided is accurate, complete and current and that I have no other insurance coverage. I assign my right to receive payment of authorized benefits under Medicare, Medicaid, and/or any of my insurance carriers to the provider or supplier of massage therapy services furnished to me by that provider or supplier. I authorize my massage therapist provider to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. If my health insurance plan does not pay my provider directly, I agree to forward to my provider all health insurance payments which I receive for the services rendered by my provider and its massage therapy providers. I authorize my provider or any holder of medical information about me or the patient named below to release to my health insurance plan such information needed to determine these benefits or the benefits payable for related services.  I understand that if my provider does not participate in my insurance plan's network, or if I am a self-pay patient, this assignment of benefits may not apply. 

Guarantee of Payment & Pre-Certification.  In consideration of the services provided by my provider, I agree that I am responsible for all charges for servcies I receive that are not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan.  I agree to pay all charges not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan.  I further agree that, to the extent permitted by law, I will reimburse my provider for all costs, expenses and attorney's fees incurred by my provider to collect those charges.  If my insurance has a pre-certification or authorization requirement, I understand that it is my responbility to obtain authorization for services rendered according to the plan's provisions.  I understand that my failure to do so may result in reduction or denial of benefit payments and that I will be responsible for all balances due.

Consent to Treatment. I hereby voluntarily consent to the rendering of such care and treatment as my providers, in their professional judgment, deem necessary for my health and well-being.  My consent shall cover massage therapy and/or manual therapy also known as bodywork.  My consent shall also cover the carrying out of the order of my treating massage therapist and professional care team.  I acknowledge that neither my provider nor any of his or her staff have made any guarantee or promise as to the results that I will obtain.

Consent to Call, Email & Text. I understand and agree that my provider may contact me using automated calls, emails and/or text messaging sent to my landline and/or mobile device.  These communication may notify me of an upcoming appointment, canceled or rescheduled appointment, preventative care, treatment recommendations, outstanding balances, treatment follow-up calls, or any other communications from my provider.  I understand that I may opt-out of receiving all such communications from my provider by notifying my provider's staff or by emailing admin@kmihawaii.com.