To submit this form, ensure that you have completed all the required fields and obtained the necessary signatures. You can submit the form via email, fax, or mail, depending on the instructions provided by the massage therapy provider or your healthcare provider. For email submissions, attach the completed form and send it to the designated email address. For fax submissions, use the provided fax number to send the form. For mail submissions, send the completed form to the provided physical address. Make sure to keep a copy of the submitted form for your records.

There are no specific important dates for this form. It can be used whenever a referral for massage therapy treatment is needed.

The purpose of this form is to provide a standardized way for patients to request massage therapy treatment based on a referral from their doctor or chiropractor. This ensures that the patient receives medically necessary massage therapy, which is considered an essential service in accordance with California Massage Therapy Council guidelines. The form facilitates communication between the patient, their healthcare provider, and the massage therapy provider.

• 1. Patient's Name: Enter the full name of the patient requesting the massage therapy treatment.
• 2. Provider Name: Enter the name of the massage therapy provider.
• 3. Provider Address: Enter the address of the massage therapy provider.
• 4. Doctor/Chiropractor's Name: Enter the name of the doctor or chiropractor referring the patient for massage therapy.
• 5. Doctor's Signature: The doctor or chiropractor must sign the form to validate the referral.
• 6. Patient's Signature: The patient must sign the form to acknowledge the request for massage therapy treatment.
• 7. Date: Enter the date when the form is filled out and signed.
• 8. Additional Notes: Provide any additional notes regarding the patient's health that may be relevant for the massage therapist.

Failure to submit this form may result in the patient being unable to receive the necessary massage therapy treatment.

• Denied Access: Patients may be denied access to medical massage therapy services.
• Delay in Treatment: There may be delays in receiving the necessary treatment for pain management.
• Insurance Issues: Patients may face issues with insurance claims and reimbursement for the treatment.

• 1. Medical Necessity: When the patient's doctor or chiropractor determines that massage therapy is medically necessary.
• 2. Insurance Reimbursement: When the patient needs a referral form to submit for insurance reimbursement.
• 3. Pain Management: When massage therapy is part of the patient's pain management plan.
• 4. Essential Service: When massage therapy is considered an essential service for the patient's health.
• 5. Provider Requirement: When the massage therapy provider requires a referral form for the patient.