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MEDICAL MASSAGE THERAPY CLAIM FORM To be completed by Patient or Massage Therapist: HEALTH PLAN ID P 2026
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- Click ‘Get Form’ to open the MEDICAL MASSAGE THERAPY CLAIM FORM in the editor.
- Begin by entering your HEALTH PLAN ID in the designated field at the top of the form.
- Fill in your PATIENT NAME and PATIENT DATE OF BIRTH accurately to ensure proper identification.
- Describe your MEDICAL SYMPTOMS REQUIRING TREATMENT clearly, as this information is crucial for processing your claim.
- Select the appropriate PROCEDURE CODE from the provided options (97124) based on your treatment.
- Enter the DATE OF SERVICE and CHARGE for each session. Ensure that you total these charges correctly in the TOTAL CHARGE field.
- Sign and date the form at the bottom, certifying that all information is true and accurate.
- Attach a receipt from a licensed massage therapist, including their complete name, address, phone number, and license number before submitting.
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