Workers' Comp (WC) 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 by Workers’ Compensation for a work-related injury. All information is confidential and used only for treatment and insurance billing purposes.

Your personal health information is protected under HIPAA. Information will be shared with your Workers' Compensation insurance carrier, claims adjuster, and/or referring physician as needed for treatment authorization and billing.

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 Workers’ Compensation Insurance CarrierPlease provide the name of your Workers’ Comp insurance carrier.

Contact Information for Your Claims AdjusterPlease provide your claims 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 InjuryPlease provide the date of your work-related injury to assist with claims and treatment planning.

Have you hired an attorney for your Workers’ Compensation claim?NoYes

Yes → Attorney name & phone:

Briefly describe your work-related injury or areas of painPlease give us a short overview of your injury and current symptoms.

Do you have a prescription or work order for massage therapy?A prescription (Rx) or work order from your treating physician is typically required for Workers’ Compensation massage therapy. Please provide it if available. We can assist you with obtaining the necessary documentation if needed.Yes (will upload or bring to first visit)No – please help me obtain one

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

Workers' Comp (WC) Massage Therapy Intake Form

Client Information

Insurance Information

Consent

Hours of Operation

Contact Information

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