Motor Vehicle Accident (MVA) Massage Therapy Intake Form

Name: RAP Manual Therapy and Massage
Price range: $$$

RAP Manual Therapy and Massage

This form is for clients seeking massage therapy covered under auto-insurance (PIP/No-Fault, Med Pay, or third-party liability) after a motor vehicle accident. All information is confidential and used only for treatment and insurance billing.

Your personal health information is protected under HIPAA and will only be shared with your insurance carrier or referring provider with your consent.

Client Information

First and Last Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birthfor your insurance

Phone *

Email Address *

Insurance Information

Your auto insurance carrierYour auto insurance will handle any claims or coordination with other parties.

Contact Information for Your Insurance AdjusterPlease provide your adjuster’s name, phone number, and email for efficient claims coordination.

Claim NumberPlease provide your claim number to help us obtain all necessary information from your insurance company.

Date of accident / Date of lossPlease provide the day of loss to assist with insurance claims and treatment planning.

Did you visit the emergency room for your injuries?Please let us know if you visited the emergency room for your injuries. This helps us coordinate with your personal injury protection (PIP) coverage and plan your treatment effectively.NoYes

please explain:Did you have to stay in the hospital, did you need surgery?

Have you hired an attorney for this accident?NoYes

Yes → Attorney name & phone:

Briefly describe your injuries or areas of pain from the accidentPlease give us a short overview.

Do you have a prescription or work order for massage therapy?A prescription (Rx) or work order may not always be required to begin massage therapy. We’ll assist you with any necessary steps.Yes (will upload or bring to first visit)No – please help me obtain oneNot requred by my auto insurance carrier

You can upload documents here if you like.

How would you prefer we contact you?Text/SMSEmailPhone call

Would you like a copy of this form?We will send you an email.NoYes

Email Address *To which email address would you like to have a copy sent?

Is there anything else you’d like us to know or any questions on your mind?

Consent

Electronic Signature *Type Full Name

Date

Motor Vehicle Accident (MVA) Massage Therapy Intake Form

Client Information

Insurance Information

Consent

Hours of Operation

Contact Information

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