1. Massage Policy
CancellationPolicy
I understandthata 24 hour notice is required whencancellingorreschedulingamassage.Iunderstand
that a $25.00 charge will be placedonmyaccount if I fail to give a 24 hournotice,andagree to pay the
cancellationfee before anyfuture serviceswillbe rendered.
Late
I understandthatif I am late I am responsible to payfor the full time that I am scheduledfor.
o Example:1 HOUR MASSAGESCHEDULED – ONLY RECEIVEA 30 MINUTE DUE TO BEING LATE –
STILL RESPONSIBEFOR THE FULL 1 HOUR PRICE.
No Show
I understandthatif I “no show” to a massage appointmentIam responsible topay for the time that I
was scheduledfor. A “noshow”is definedasnotcallingtocancel yourappointmentornotshowingup.
WhenInsurance covers Massage Therapy
The cancellation,late andnoshow policies all applywhenusinginsurance,andwillbe chargedthe cash
price as we will notcharge insurance forthe listedreasons.
Whenusinginsurance tocoverany massage the followingapply.
o The patient/clientmust follow the Doctor’srecommended care planforbothChiropractic&
Massage.If youdo not follow acare plan to correctthe currentissuesthismay be considered
maintenance care and massage will be considereda non-billable service.
o Massage coverage is basedoff ofthe Chiropractic Exam todetermine Medical Necessity.
o Length,frequencyandwhichareasmassage isperformed are determined duringthe
ChiropracticExaminationandfurtherdiscusseduponassessmentof the Massage Therapist.
Orthopedic&Neurological Testing,Range of Motions,&Palpationare decidingfactorsthat
determine Medical Necessity.
o MonthlyRe-examinationsmustbe performedby the Doctor to re-assessprogressand to
determine Medical Necessity.Thisisimportantnotonlyfor ChiropracticCare,butalsofor
Massage.The length,frequencyand which area(s) massage is to be performedoftenchanges
as the patient progresses/regresses.
o A Massage will not be performedonthe same daythat a Re-examinationisscheduledfor.
o Massage benefitsquotedtousbyyour insurance company isnot a guarantee of payment.
Paymentsfornon-coveredservicesare due byyouat the time of service orbefore anyfuture
visitswill be rendered.
PRICE: 30 Minute Massage: $35 60 Minute Massage: $65 90 Minute Massage: $95
By signing this policy I agree to pay in full any money owed within 30 days, and/or before any future services are rendered.
Patient/ClientSignature: Date:
Therapist: Date:
