Motor Vehicle Accident Coverage Request Form

 
 
 

If you have recently been in a motor vehicle accident, please don’t wait to begin your path to recovery! Once you have obtained a referral from a primary care physician and would like to continue treatment through massage, please submit any and all pertinent information (date of accident, insurance company, claim number, claims adjuster, contact phone numbers) to find out if your sessions can be covered. Please allow 2 business days for verification.

 
Client Name *
Client Name
Client Birth Date *
Client Birth Date
Client Daytime Phone *
Client Daytime Phone
Insurance Company Phone Number *
Insurance Company Phone Number
Date of Accident *
Date of Accident
Attorney Phone Number
Attorney Phone Number
Please Check your preferred method of contact for appointment confirmation *