Date: January 18, 2020
MASSAGE CLIENTS ONLY:IF YOU WOULD LIKE US TO DIRECT BILL FOR YOU PLEASE NOTIFY THE FRONT DESK & FILL OUT THE FOLLOWING ASSIGNMENT OF BENEFITS.
*Please note, the decision of coverage is solely your insurance providers*
Assignment of Benefits
I request that payment under my medical insurance program be made to ONE WELLNESS for any services or equipment furnished to me. I authorize ONE WELLNESS to release any information needed for this claim to the necessary carriers or their intermediates. I also request that a copy of this authorization be used in place of the original.
Statement of Confidentiality
I authorize the release of necessary medical information to ONE WELLNESS for the purposes of processing this or any related insurance claims. I also give ONE WELLNESS the authority to make available any requested documents contained in my file to myself and/or other healthcare providers involved in the treatment of my condition.
I acknowledge that I am fully responsible for the payment of any services and equipment provided to me by ONE WELLNESS. I understand that if ONE WELLNESS submits a claim for billed charges to my health plan(s) on my behalf, I am not relieved of my financial responsibility for payment. In the event that the health plan or any third party payer does not pay the entire billed amount, I agree to pay any remaining balance.
By signing below, I acknowledge and accept the terms and conditions stated above.
**Must be completed by guests 18 years of age and older**
I acknowledge that I am at least 18 years of age and that the treatments provided at One Wellness and Spa are not intended as a
diagnosis and do not replace medical treatment. I further acknowledge that the information I have provided is true, accurate and
complete and that certain treatments may be refused to me on the basis of the information provided herein.