Verification Request Form | Verification Request Form

Contact Information

First and Last Name (as listed on your policy)

Date of Birth

Preferred name and/or pronouns (if different than on your policy).

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Which services are you interested in?

Massage Therapy/Manual Therapy w/ Body Aware Massage LMTs
Acupuncture, Cupping, Facial Rejuvenation Acupuncture or Chinese medicine consultations with Dr. Haley Bott DACM, LAc
Mental Health Counseling w/ Karel Chan, LPC, LMHC

Please note:

Massage services: Currently massage services are In-Network with Pacific Source, Regence/BCBS, Providence (until 9/1/25) and MVA claims. All other plans would be considered out-of-network and require payment at the time of service. For out-of-network claims we are unable verify coverage in advance but can provide a detailed receipt (with treatment codes) for you to submit for possible reimbursement by your insurance company.

Acupuncture & Mental Health Counseling: Coverage varies by plan and provider. If are you are interested in these services, complete this form and we will forward your request to Dr. Haley Bott DACM, LAc or Karel Chan, LPC, LMHC.

Insurance Type

Other/Out-of-Network Insurance Company Type

Please list name of insurance company or plan name type.

Insurance ID (please include alpha prefix if your ID contains one)

MVAs use Claim #

Group #

Gender (as listed on your insurance policy)

Are you the Primary Insured? (Primary account holder on this policy)

Yes
No
N/A

Primary Insured first and last name (as it appears on insurance card)

Primary Insured Date of Birth

Your relationship to the insured (spouse, child, etc)

Is your address and the address of primary insured the same?

Yes
No

Address

Address Line 1

Address Line 2

City

State

Zip Code

and Insured Concern

Treatment & Concerns

Primary Concern

Any other concerns or anything you would like us to know?

MVA Information

MVA- Car Insurance Carrier

Please list your car insurance company, regardless of fault.

Date of Accident

Claims adjuster name and phone number

Please list the insurance company you are insured with, regardless of fault.

If you are represented by an attorney, please list their name and phone number

Attach a photo of the front & back of your insurance card here

Click or drag a file to this area to upload.

Policies & Disclaimers

Privacy Policy

The information in this form includes your legally protected health information to be stored securely and kept confidential unless required by law. Your health information will only be shared with the providers involved in your treatment and office staff for the purpose of eligibility or pre-authorization submitted to your insurance company.

Our complete privacy practices and policies are listed online https://bodyawaremassage.com/privacy-policy/ and a written copy can be provided by request.

Today's Date

By signing below, I consent to my personal health information being collected and stored and that I have been informed of my privacy rights.

Clear Signature

INSURANCE VERIFICATION FORM