Forms & Rescources

Please see below for downloadable forms and company policies-

Healthcare Provider Referral Form

Download, print and take this form to your provider to obtain a medical referral for Myofascial Release for medical insurance billing purposes.

Healthcare Provider Permission Form

Download, print and take to your provider to obtain a medical release for Myofascial Release, massage and other bodywork treatments.

Authorization to Disclose Information

Download, print and fill out this form to authorize release of your records to another party.

HIPAA Notice of Privacy Practices

Click link to open notice. 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.

Billing Policy

If this office is providing billing services, please be advised of our billing policies:

Cancellation:

We do not bill insurance companies for missed appointments or late cancellations. You are responsible for paying the missed appointment/late cancellation fees according to our Cancellation Policy.

Financial Responsibility:

We will bill and accept payment from your insurance company for covered services. In the event that the insurance company denies payment or makes partial payment, you are responsible for the balance, deductibles, and co-pays. Your signature on the consent confirms your financial responsibility for all services regardless of insurance reimbursement.

Assignment of Benefits:

Your signature on the consent authorizes and directs payment of medical benefits to Morningsky Myofascial Release LLC for services provided by this office.

Release of Medical Records:

Your signature on the consent authorizes the release of any medical and insurance information necessary to process any claim.

Cancellation Policies

In my desire to be fair to all clients, the following policies are enforced:

Cancellation Policy:

24 hour notice is required when canceling an appointment or you will be charged 50% of your appointment fee.

No-shows:

Anyone who forgets or chooses to forgo their appointment without notice will be considered a no-show. All no-shows will be charged the full amount of their appointment. This fee is due before your next session. All future bookings will require prepayment.

Late Arrivals:

If you arrive late your session will be shortened in order to accommodate other appointments. Arrivals 15 minutes late will be considered no-shows. Regardless of treatment length clients will be responsible for the originally scheduled session fee.

Sickness:

Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived.