MEDICAL MASSAGE THERAPY CLAIM FORM To be completed by Patient or Massage Therapist: HEALTH PLAN ID P 2026

1. Click ‘Get Form’ to open the MEDICAL MASSAGE THERAPY CLAIM FORM in the editor.
2. Begin by entering your HEALTH PLAN ID in the designated field at the top of the form.
3. Fill in your PATIENT NAME and PATIENT DATE OF BIRTH accurately to ensure proper identification.
4. Describe your MEDICAL SYMPTOMS REQUIRING TREATMENT clearly, as this information is crucial for processing your claim.
5. Select the appropriate PROCEDURE CODE from the provided options (97124) based on your treatment.
6. Enter the DATE OF SERVICE and CHARGE for each session. Ensure that you total these charges correctly in the TOTAL CHARGE field.
7. Sign and date the form at the bottom, certifying that all information is true and accurate.
8. Attach a receipt from a licensed massage therapist, including their complete name, address, phone number, and license number before submitting.

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