Patient Forms

Please use the following links to print and fill out our insurance coverage and patient health history forms. The forms are in the PDF format; in order to view them you will need a PDF viewer such as Adobe Reader. If you do not have Adobe Reader you can click here to download it FREE.

get_adobe_reader

FOR ALL NEW CHIRO PATIENTS: Please use the following link to print the New Patient Forms.  Please bring the completed forms to your first visit.  This will help us to minimize delays during your appointment.  Please allow 60 to 75 minutes for your initial examination appointment.

NOTE TO NUTRITION PATIENTS:  You will find Nutrition forms under OUR SERVICES on the navigation bar located on the right side of the screen.  Forms on this page are for Chiropractic Patients ONLY.

Click here for New Chiro Patient Packet 

FOR CHILDREN & MINOR PATIENTS ONLY: For patients under the age of 18, please complete the following form IN ADDITION TO THE NEW PATIENT FORMS ABOVE.

Click here for Consent for Treatment of Minor Child

TRANSFER OF MEDICAL RECORDS: To transfer medical records, X-Rays or other scans to our office, please complete the following release form.

Click here for Authorization for Medical Records Release

USING YOUR INSURANCE:  We attempt to take out as much of the “insurance hassle” as possible for you. We’ll happily phone your insurance company to verify your coverage of benefits. Please remember, however, that benefits quoted to us by your insurance company are not a guarantee of payment. We encourage our patients to also take time to verify their coverage. We will file your claim and await payment for 60 days. If your company pays the benefits they quote to us, you will only be financially responsible for any non-covered services, deductibles, co-insurance or co-pays.

As insurance deductibles, co-pays and co-insurance have increased dramatically, many of our patients find it difficult to keep pace with the cost of achieving good health. We have created flexible payment options that can help. If you have any questions about this, or any other financial questions, please do not hesitate to ask. Our staff has extensive experience in working with insurance and will be happy to assist you.

PATIENTS WITHOUT INSURANCE: An increasing number of patients do not have insurance. We realize that no one wants to build up a large bill. Therefore, we have several payment options so that those patients may receive complete care without undue financial difficulty,. Of course, we are always happy to accept cash, your personal check, MasterCard, Visa or Discover cards.

ABOUT MEDICARE:  We accept assignment from Medicare. Medicare has very limited chiropractic coverage. It covers 80% of chiropractic adjustments after the Part B deductible is satisfied. Medicare does not cover the cost of the initial examination, x-rays, or other services. These non-covered charges, as well as 20% of the chiropractic adjustment is patient responsibility. We will file your Medicare or Medicare Replacement claims as a courtesy.

ABOUT MEDICAID:  Our office does not accept assignment from Medicaid.

ABOUT PERSONAL INJURY or AUTO ACCIDENT CASES:  Please call our office to discuss your case.  Each case is reviewed and accepted on an individual basis.  Please notify your auto insurance carrier immediately of your visit to our office. You will need to provide the claim number and the contact information for the insurance carrier. Our insurance department will work with your advocate to arrange payment. Although you are ultimately responsible for services you receive in our office, we will wait for settlement of your claim up to three months after your care is completed. Once the claim is settled, or if you suspend or terminate care, any fees are due immediately.

ABOUT WORKERS COMPENSATION “On The Job” INJURY CASES:   We do not accept Workers Compensation cases.

 

Pin It