INSURANCE BILLING
Personal Insurance
I employ Three Sisters Medical Billing Service to efficiently bill your insurance for you if your insurance provider covers massage therapy.
There are some personal insurance companies that cover massage benefits. Call your insurance company and ask if massage is a covered service by a licensed massage therapist (note that some policies cover massage but only when done by a physician or physical therapist). I require pre approval for all insurance claims before your first visit or you can pay at the time of service using the pre pay discount. I will hold this payment until your insurance is approved. Please contact me via email at shenasmassage@gmail.com or phone, 541-977-3874 with your insurance information and my insurance billing service will obtain the massage benefits for you.
Car Insurance
If your injury is from a car accident and is an open claim most car insurance will cover massage during the first year following the accident. Call your insurance company and ask if a prescription is needed.
I require pre approval for all insurance claims before your first visit or you can pay at the time of service using the pre pay discount. I will hold this payment until your insurance is approved. Please contact me via email at shenasmassage@gmail.com or phone, 541-977-3874 with your insurance information and my insurance billing service will obtain the massage benefits for you.
Worker's Compensation Insurance
If your injury is from an on the job accident and you have an open claim you can usually receive massage benefits with a Dr.'s prescription and a treatment plan from your attending physician.
I require pre approval for all insurance claims before your first visit or you can pay at the time of service using the pre pay discount. I will hold this payment until your insurance is approved. Please contact me via email at shenasmassage@gmail.com or phone, 541-977-3874 with your insurance information and my insurance billing service will obtain the massage benefits for you. Financial Policy
Shena Fields, LMTThank you for choosing Shena Fields as your massage therapy provider. I accept cash and insurance reimbursement for your massage therapy. I offer insurance billing as a service of my practice and absorb the cost of billing your insurance. My billing service company, Three Sisters Medical Billing, will work very hard to make sure your paperwork is filed accurately and promptly. I require pre-authorization for massage services to efficiently facilitate reimbursement from your insurance company. My billing service will usually be able to confirm your massage benefits and requirements for eligibility within 24 hours of receiving your information. Please note that you might benefit by taking advantage of the discount I provide when you pay at time of service and bill your insurance for reimbursement yourself. If you choose this option I will provide you with a receipt for the massage service.
Massage Therapy Prices
Paid at Time of Service Discount
Deep Tissue Therapeutic Massage per 15 minutes $15.00
Swedish Relaxation Massage per 15 minutes $15.00
Heat Application per application No Charge
Neuromuscular re education per application No Charge
No Discount Prices
Deep Tissue Therapeutic Massage per 15 minutes $50.00
Swedish Relaxation Massage per 15 minutes $42.50
Heat Application per application $20.00
Neuromuscular re education per application $30.00I ACCEPT ALL MAJOR CREDIT CARDS, (except Amex & Discover) DEBIT CARDS, CHECKS AND CASH. Insurance & Insurance Collection:
Please understand that insurance reimbursement can be a long and difficult process. In fact, insurers will routinely stall, deny, and reduce payments. To that end my billing service provider, Three Sisters Medical Billing, has undergone extensive and rigorous training to maximize your insurance reimbursement, while reducing the time by which they pay. To help speed up payment and eliminate any confusion in the future, please initial next to your category of insurance listed below. Worker’s Compensation Insurance Plans:
____Three Sisters Medical Billing will bill your insurance as a courtesy. You will need to have a prescription from your attending physician for massage therapy and confirm with your adjuster that you are authorized for massage therapy services. I accept the discounted rates your insurance carrier will negotiate as full payment for services. If your claim is denied you will be responsible for the remaining balance.
Auto Accident (PIP):
____Three Sisters Medical Billing will bill your insurance as a courtesy. You will need to provide a prescription from your physician for massage therapy and confirm with your adjuster that you are authorized for massage therapy services. I accept the discounted rates your insurance carrier will negotiate as full payment for services. If you claim is denied you will be responsible for the remaining balance.
Non-Contracted or Indemnity Insurance Plans:
_____ Three Sisters Medical Billing will bill your insurance as a courtesy. In order to expedite your insurance payment please pre-authorize the “letter for insurance stalls”. In the event that your insurance does not reimburse me within 45 days, Three Sisters Medical Billing will transfer the balance of your account to your credit card or you can send a check. Please indicate your preference.
_____ Transfer my balance. ______ Call first, I might want to send a check.
Plans in which I am a participating provider:
______ I have agreed to accept the discounted rate from your plan, however, all co-insurance or co-payments are your responsibility. Three Sisters Medical Billing will estimate your co-payment to the best of their ability. The co-payment must be paid at the time of service. After your insurance has cleared, Three Sisters Medical Billing can transfer any remaining balance to your credit card, or you can send a check. Please indicate your preference.
_____ Transfer my balance. ______ Call first, I might want to send a check.
Self-Insured/Union Plans:
Three Sisters Medical Billing Service has been thoroughly trained on how to get reimbursed by your employer. In the event there is a problem, you will need to provide Three Sisters Medical Billing with the name of your human resources director and/or benefits manager. They may also require your authorization to file complaint letters to the Department of Labor and your administrator.
______ If I am not contracted with the plan administrator of your employer, Three Sisters Medical Billing will bill your plan as a courtesy. In the event your plan has not reimbursed me within 45 days, Three Sisters Medical Billing can transfer the balance of your account onto the credit card on file or you can send a check. Please indicate your preference.
_____ Transfer my balance. ______ Call first, I might want to send a check.
Secondary Insurers:
_____Having more than one insurer DOES NOT necessarily mean that your services are covered 100%. Three Sisters Medical Billing will bill your secondary carrier as a courtesy. You are responsible for any balances after your insurance(s) has cleared.
Usual & Customary Rates:
My practice is committed to providing the best treatment for my clients and I charge what is usual and customary for our area. You are responsible for payment regardless of the insurance company’s arbitrary determination of usual and customary rates.
Divorce Decrees:
This office is NOT a party to your divorce decree. Adult clients are responsible for their bill at the time of service. The responsibility for minors rests with the accompanying adult.
Minor Patients:
The adult accompanying a minor and the parents (or guardians) of the minor are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, Visa/MasterCard, or payment by cash or check at the time of service.
Thank you for taking time to understand my Financial Policy. Please let me know if you have any questions or concerns.
Please sign below to indicate the following:
I have read the Financial Policy.
I understand and agree with this Financial Policy.
I assign my insurance benefits to Shena Fields, LMT.
Signature of Client or Responsible Party:
X_________________________________________ Date:____________________________
I authorize Three Sisters Medical Billing to maintain my credit account on file.
Cardholder Signature:________________________________
Account#: ________________________________________Exp:______
Shena Fields, LMT
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Shena Fields LMT is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Disclosure of Your Health Care Information Treatment
I may disclose your health care information to other healthcare professionals within my practice for the purpose of treatment, payment or healthcare operations.
Payment
I may disclose your health information to your insurance provider for the purpose of payment or health care operations.
Workers’ Compensation
I may disclose your health information as necessary to comply with State Workers’ Compensation Laws.
Emergencies
I may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
Public Health
As required by law, I may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
Judicial and Administrative Proceedings.
I may disclose your health information in the course of any administrative or judicial proceeding.
Law Enforcement.
I may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
Public Safety.
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Change of Ownership.
In the event that Shena's Massage LLC is sold or merged with another organization, your health information/record will become the property of the new owner.
Your Health Information Rights
- You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Shena's Massage LLC is not required to agree to the restriction that you requested.
- You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
- You have the right to inspect and copy your health information.
- You have a right to request that Shena's Massage LLC amend your protected health information. Please be advised, however, that Shena's Massage LLC is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial.
- You have a right to receive an accounting of disclosures of your protected health information made by Shena's Massage LLC.
- You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices
Shena's Massage LLC reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Shena's Massage LLC is required by law to comply with this Notice.
Shena's Massage LLC is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Shena Fields LMT by calling this office at 541-977-3874. If Shena Fields LMT is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.
Complaints
Complaints about your Privacy rights, or how Shena's Massage LLC has handled your health information should be directed to Shena Fields LMT, by calling this office 541-977-3874. If Shena Fields LMT is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.
If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
To file complaints by e-mail go to:
OCRComplaint@hhs.gov.
For complaints involving covered entities
located in Alaska, Idaho, Oregon, or Washington:
Region X, Office for Civil Rights, U.S.
Department of Health and Human Services
2201 Sixth Avenue—Suite 900
Seattle, Washington 98121–1831
Voice Phone (206) 615–2287
FAX (206) 615–2297
TDD (206) 615–2296