Lighthouse Massage
Burton BodiWerks

Helpful Forms

The following forms are designed to help us work together more easily to safely acheive your health goals.  Check the list to see what forms you'll need to bring to your appointment! If you have any questions let us know!

If you are interested in viewing the official version of HIPAA, all federal regulations are published in the Code of Federal Regulations (CFR), and HIPAA regulations are dispersed within Public Welfare in 45 C.F.R. Part 160, Part 162, and Part 164.

Non-Insurance Client Intake

If you are a first-time client without insurance coverage for massage, please print this 1 page form, complete it, and bring it along to our first session with your signed Fee, Policy, and Waiver form and HIPAA page.

Medical Massage/Insurance Intake

If you are a first-time client with health insurance that covers massage or accident insurance with a medical referral, please print and fill out this 2-page form and bring it with you, along with a copy of your Insurance information, ID card, and referral for massage. There is a Rererral Form on this page if you would like to print and submit it to your doctor/chiropractor for them to fill out and either bring it or have them fax it to our office. Check with your health insurer to make sure massage is covered, your co-pay at time of service, and whether your deductible is met.

HIPAA Privacy Policy

Please read, print and fill out the last page of this form and bring with you to your Massage or Training appointment.

Fee Policy and Waiver Form

This is a 3 page form for first-time clients. It explains clinic policies, procedures and fees. The last page is a waiver/agreement for you to print, sign and bring to your appointment.

Neck Disability Questionnaire

Please print and fill this form out if you have a chronic neck problem so we can better help you.

Intended Outcomes Form

This form will help you clarify your goals for your overall health and vitality, including our time together.

Referral and Prescription Form

If you need a referral from your medical provider for Medical or Therapeutic Massage, you can print this form out and give it to them. The provider can either return the completed form to you or our office.

Customer Reference Form

If you'd like to share your story/comments/review with others on the website, print and fill out this form and mail it, drop it off, or send an email to Lighthouse via the Contact Me page.

HIPAA Information

Your medical records are confidential! HIPAA regulatory standards in one document. 115 pages. Current as of March 2013. This is an unofficial version that presents all the HIPAA regulatory standards in one document.

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