Emergency Contact Information
Auto Accident-PIP Insurance
Please fill out only if you are being seen for a motor vechicle accident. You need to have PIP on your own insurance and you must have a claim number with your own insurance company and have signed you PIP documents. You will also need a prescription with the medically necessary diagnosis and schedule of treatment. All this info and Rx need to have been provided to the clinic prior to your scheduled session for use to pre verifiy unless you are paying out of pocket the same day.
Labor & Industry/Worker Compensation
Please fill out only if you were injured on the job and have your approved Rx for the claim. Please upload that Rx and approval her with your form for us prior to your scheduled session unless you are paying out of pocket.
Please Note: Please fill out only if you are a health insurance client, have a medically necessary diagnosis on a prescription with a schedule of treatment. Although some insurances say you do not need a referral nor Rx, we must have one because we have no one on staff that can diagnose you in order to submit your claim. It is also the patients responsibility to know their insurance benefits and coverage. Please note that Alexis has requested removal as an in network provider for all insurance companies except United Health Care, effective July 31st 2017. You will be required to pay the same day payment at time of service and the clinic will provide you a super bill to submit to your insurance company. At your request, with the proper documents, payment and approvial, Alexis will submit your claim to your health insurance on your behalf.
Please Read The Following Before Signing
PLEASE NOTE: When you submit your form, please make sure you get the confirmation on the screen with a big green check mark saying "your form was submitted succesfully".
If you do not get this, it means you need to scroll up and correct the mistakes listed in red.
All Neuro Sessions - No Lotion/Fully Clothed Unless otherwise instructed please plan to come or bring with you your gym/yoga clothes (knees need to be exposed or snug uyoga pants), The clinic uses 'dry modalities' while you are fully clothed. Please do not wear any body lotions or oils on the day of your session!
Client Disclaimer: I, the undersigned, understand that I am receiving neurological based bodywork unless otherwise noted on the intake form or at the consultation. I also understand that I am seeking analysis and/or therapies that may not be FDA registered or approved and may not be offered by other participating physicians (allopathic or otherwise) and may be considered experimental. These include but not limited by fascia blasting, essential oils, massage & bodywork using CHABA creams and oils, recommended movement therapy or exercise, stretches and neuor frequency disc's (frequency patches). I understand that although some clients ask for extremely deep compression, it is preferable to keep the compression at a therapeutic level. The therapist will determine the appropriate level for each individual. Do to the serious nature of all deep tissue techniques and fascia blasting, it is imperative that you understand that you should express pain, stiffness, soreness, skin irritations, marks, headaches, sinus congestion, bruises or any injury, sugery, scars or conditions, and that you do not hold Pain To Performance PLLC, Pain To Performance dba, Spa Alexis dba, Spa Alexis Massage & Bodywork dba and Alexis Kurtzman liable. In addition, if you request for more compression on a higher level than that of a therapeutic range than the therapist is delivering, Pain To Performance PLLC and Alexis Kurtzman will not be held responsible for aggravating a condition that may already be present.
In addition: Even though I am seeking alternative healing suggestions and therapies, I understand that bodywork/massage therapy/ Personnal Trainning, Coorective Exercise, Yoga Therapy and Weightloss Consulting should NOT be constructed as a substitute for medical examination, diagnosis, or treatment, and that I should see a Physician for any physical or mental ailment that I am aware of. I understand that Pain To Performance PLLC, Pain To Performance Soutions dba, Spa Alexis dba, Spa Alexis Massage & Bodywork dba and Alexis Kurtzmanare are qualified licensed bodywork clinics that specializes in facilitating the relief of chronic and acute pain through therapeutic bodywork. Pain To Performance PLLC/Alexis Kurtzman are NOT institutions of major medical care, chiropractic, physical therapy or occupational therapy care. Massage therapy is NOT a substitution for medical examination and or diagnosis. At SPain To Performance PLLC you will only recieve massage-bodywork-manual movement therapy, corrective exercise, personal training, yoga therapy, weighloss consulting from federally licensed massage therapists and certified technicians. We DO NOT employ unlicensed. A licensed massage therapist does NOT diagnose illness, disease, or other physical or mental disorders. They also do NOT prescribe medical treatment or pharmaceuticals, nor do they perform spinal manipulations. Licensed Massage Therapist who are trained and certified in provide various assessments prior, during and after treatment, which may consist of a static posture assessment, transistional assessments, fuctional muscle testing, treatment and homework. Licensed massage therapist who are certified in personal training, corrective exercise and yoag may also give detailed homework on which movements to do and how many. Information exchanged during any session is confidential and will not be shared or released without your written consent or a court order. I affirm I have stated ALL my medical conditions to the best of my knowledge, and I will NOT hold SPain To Performance PLLC, Alexis Kurtzman nor the massage therapist liable, therefore, I understand that massage therapy-bodywork-manual movement therapy is for the purpose of stress reduction, improved range of motion, mobility, relief of muscular tension, spasm, pain, improving posture, for increasing circulation, reduction of inflammation, improve fuction of muscles and energy and is NOT major medical care or chiropractic care. The undersigned does herby release Pain To Performance PLLC, Alexis Kurtzman and or the massage therapist of any and all liability pertaining to any present or future physical or mental conditions that I may have.
Please note: At Pain To Performance PLLC, inappropriate action, language, sexual misconduct or sexual harassment is NOT tolerated and is cause for immediate termination of services with no refund. Pain To Performance PLLC and Alexis Kurtzman LMP LMT LMTI CPT, CES NKT ANF MMT reserves the right to refuse services to anyone. In addition if the client or the therapist is uncomfortable for any reason, either the client or the therapist may ask to cease the session at any time and the treatment will be ended immediately. I certify that I seek the advice of Pain To Performance PLLC/Alexis Kurtzman soley in my personal compacity, and do not represent any govermental agency, law firm, attorney, or investigator. I am not involved in a lawsuit (unless it is a motor vechile accident or injured on the job) nor am I gathering information for a ptential lawsuit. I understand and agree on behalf of myself, my dependents, heirs, administrators, legal representatives, and assigns, to release and hold harmless Pain To Performance PLLC/ Alexis Kurtzman and any and all associates, employees, agents and representatives thereof, from any and all liabilities for illness, injuries, or death, and for any losses or damages relating thereto, however occuring, in relations to the consultation with and/or treatment by Pain To Performance PLLC/Alexis Kurtzman. Without limitation, I understand and agree that neither Painn To Performance PLLC/ Alexis Kurtzman, nor any associates, employees, agents or representatives therof, is liable for any direct, indirect, consequential, or incidental damage, injury, death, loss, delay, or inconveniences of any kind which may be occasioned by reason of any act or omission, including, without limitation, any willful or negligent act or failure to act, or breach of contract. Due to being a very small business, there is absolutely no refunds on any services or purchased items. I also understand 24 hour notice (business days) by phone or text message is needed for any cancelations or reschedules otherwise I will be charged the full price of the appointment with my credit card on file or with my prepaid service. This includes if I fail to call or show up. If you need to cancel or reschedule on a Monday it needs to be done by Friday at 5pm since we are closed on Saturday and Sundays. I also understand e-mails are not a preferable way to cancel or reschedule since it may not be seen right away and could get lost in the 100's of business e-mails received daily. In addition, I give my permission to Pain To Performance PLLC and Alexis Kurtzman to communicate with me through forms of phone calls, text messaging, e-mails and direct mail. I have read the intake form and the above and have answered truthfully to the best of my knowledge. I understand that these are the policies of this office and my signature below signifies acceptance of these policies.
Treatment Results & Physical Responce: Please be aware that certain services such as Fascia Blasting, Cupping Therapy and Gua Sha can and may result in extreme redness and brusing to the surface of your skin, you can even feel possible sore, ill or tired from it due to the bodies responce in release of biochemical properties. In addition, any form of deep tissue work can also result is bruising and possibly feeling dizzy, light headed or tired afterwards. Also, everyone responds differently to all treatments provided. It is very common to feel worse and have more pain before feeling better and decreased pain. There are some people this never happens to but there are some it does. Also, if you have been in pain, need rehab, have sore muscles and we are also working to improve your sports performance you may feel improvement after one session but most people need more then just sixty or ninty minutes on the table. Depending on what's going on a client-patient may want to plan on long term treatment goals untill we start seeing improvments.
Cancelations & Reschedules: 24 hour notice (business days) is required for all cancellation and reschedules or you will be charged in full for the appointment. Payment is due on the day you missed and your credit card used for booking will be used or a deduction from unused sessions will be applied. If you need to cancel or reschedule on a Monday it needs to be done by Friday at 5pm since we are closed on Saturday and Sundays.
Tardiness: Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. Please be on time to your appointment. 15 minutes early for new clients and 5-10 minutes early for existing clients.
Sickness: Massage and bodywork is not appropriate care for infectious or contagious illness. Please cancel you appointment as soon as you are aware of an infectious or contagious condition. If you have given 24 hour notice, the cancellation fee will be waived. We understand emergencies happen and will take into consideration if one does occour.
Refunds: There are "no refunds" for any services, unused series packages nor unused package. Some series have an experation date and some do not, they are meant for the client-patient who comes in frequently on a weekly basis. If is the clients responsibitlity to know when their series may expire (it is on your sign in sheet every time you come in). If the series has no experation the value will never expires and any unused portion will stay on the account and can be used towards another service or item at a future date. You may also choose to have a gift certificate provided for the balance that you may gift someone. If you have one that is expired, simply purchase another series and we will roll it over.
Privacy Practice - Clients Rights: Clients may request, in writing to see or obtain a copy of their records. The client may request that corrections be made if they identify errors or mistakes. Access to records will be made during regular business hours within 30 days of receipt of written request. A clerical fee will be charged for copying and sending of non electronic requested records. Requested records are sent by fax unless the client requests that they be sent via standard mail or express mail (at client’s expense). Payment for all must be recieved prior and is sent and paid via an invoice.
Security and Use of Records:Client records are used to document client health and treatment session information. All records when not in use are maintained and locked up.
Disclosure of Records:Client records and information is only released with a written authorization on our HIPAA release of information form from the client unless compelled or required by federal, state or local laws (such as court order, subpoena, warrant, summons, discovery request, or other lawful process). The release forms will be faxed or e-mailed to the client up on request with a 72 hour turn around time.
Video/Photography Consent: Treatment at Pain To Performance PLLC may include the capture of video or still photography to document client’s progress (posture, range of motion, movement and other) and may serve as supporting material for self-care exercises at home (movement instruction). Videos and/or still photographs will never be shared with anybody other than the client and the therapist unless specific permission is granted by the client.
Please Initial - Will Only Apply If This is a PIP, L&I or Health Insurance Appointment
Cancelations: 24 hour cancelation and reschedule policy. We do not and can not bill insurance companies for missed appointments or late reschedule-cancelations. You are responsible for paying the full missed appointment, late reschedule-cancellation fees with your credit card on file and is due on the day you missed. Same day payment pricing will apply, so please give 24 hour notice for all so we will not have to charge you. If you need to cancel or reschedule on a Monday it needs to be done by Friday at 5pm since we are closed on Saturday and Sundays.
Financial Responsibility: Depending on your insurance, Once your insurance is verified, we bill and accept payment from your insurance company for covered services only if we are in network, PIP (no 3rd party) or state LNI. In the event that the insurance company denies payment or makes a partial payment, you will be responsible for the balance, deductibles and co-pays for all out of network and PIP. All out of network services need to be paid in full at time of service. As of 2019 a credit card will need to be kept on file for those non paid fees incase you exhaust your PIP. We will first let you know prior to charging your credit card. You will receive your explanation of benifits and your patients responsibity will be listed. Your signature below confirms you’re financial responsibly for all services regardless of insurance coverage or reinbursment. An invoice for the remaining balance will be sent to you from us and is do upon receipt if we can not charge your credit card on file. If you are in a motor vechile accident and we are billing your PIP and you exhaust it, all balances owed are due right away and you agree to pay us prior to your settlement as per stated above with a credit card on file. If you have health insurance as a back up after exhausting your PIP, if we are in network we will submit the remaining balance to your medical insurance. If you are out of network after we collect the balance we will give you the super bill for you to submit to your own insurance company.
As of 1-1-2019 We will no longer be able to submit to out of network insurance on your behalf, due to time and cost. We will provide you a super bill with all necessary documentation, but keep in mind we can not diagnos you so that need to come from your doctor.
Late Payment Fees on Exhausted PIP or other: If you exhaust your PIP coverage and there is a balance owed and we did not receive payment as agreed to above, there will be a $25 per month late fee added to your balance owed.
Assignment of Benefits: Your signature below authorizes and directs payment of medical benefits to the massage/bodywork practitioner for services provided by this office. Sometimes the insurance carriers will accidently send you a check that belongs to us; before you deposit it, make sure it is not meant for us otherwise the insurance comapny will require you to pay them back.
Release of Medical Records: Your signature below authorizes the release of all of your medical records on file in this office, for the purpose of processing your claim, to the following: your attorney, the healthcare providers attending to this condition, and the insurance case managers. Medical records will not be edited unless otherwise stated in an exclusive release of medical records signed through your attorney.