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.

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NEW PATIENT FORMS

Please take a few minutes to print out our New Patient Forms and fill them out as much as possible before your first visit.

PERSONAL INJURY FORMS

If your visit to our office is due to an automobile accident, please complete this Personal Injury Questionnaire before your first visit:

BACK QUESTIONNAIRE

If you are experiencing back pain, please complete this back questionnaire before your first visit:

NECK QUESTIONNAIRE

If you are experiencing neck pain, please complete this neck questionnaire before your first visit:

HEADACHE QUESTIONNAIRE

If you are experiencing headaches, please complete this headache questionnaire before your first visit:

RETURNING PATIENT

If it has been more than 3 months since your last visit to our office, please print out this Returning Patient paperwork and bring in to our office at your scheduled appointment.

NUTRITION CONSULTATION FORM

 

PATIENTS WITHOUT INSURANCE

Our office offers all patients a Time of  Service Discount.  This discount is 15% off of our standard fees.  All services must be paid at the time the service is rendered and your claim will not be submitted to insurance.  Please call our office for more information.

GROUP OR INDIVIDUAL INSURANCE

When possible, we will call to verify benefits on your insurance. However, the benefits quoted to us by your insurance company are not a guarantee of payment. Payment will be due from you at the time of service for any non-covered services or co-pays.

“ON THE JOB” INJURY (Worker’s Compensation)

If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has not been made within 3 months, or if you suspend or terminate care, any fees and services are due immediately.

PERSONAL INJURY OR AUTOMOBILE ACCIDENTS

We have two options for Personal Injury Patients.  The first option is that you can pay as you go and we will give you a walk out receipt for each visit.  You would then turn in your receipts to your automobile insurance carrier or attorney and they would be responsible for reimbursing you.  The second option is that you can use your automobile insurance med pay.  If someone else is responsible for the accident, we will file your claims through your auto insurance.  Your insurance company would pay us for your medical services and they would obtain reimbursement from the other party.  If you are responsible for the accident, you still have med pay benefits and we would file your claims through your auto insurance and they would reimburse us for your medical services.  If you are interested in utilizing the second option, please contact your automobile insurance company to verify your med pay and to authorize its usage, and then call our office with your claim number, auto insurance carrier name, contact information, and phone number.  We do not file claims through third parties (eg. Attorney’s).

MEDICARE

We accept assignment for Medicare.  For chiropractic care, Medicare only covers the manipulation of the spine; all other services are non-covered.  Medicare will reimburse 80% of the allowable fee once the deductible has been met.  We will file your claim with Medicare, however, you will be responsible to pay for all non-covered services on the day the service was rendered.  Once Medicare processes your claim, you will will be responsible to pay the remainder balance.

SECONDARY INSURANCE

Please inform us of any secondary insurance you may have.

MANAGED CARE PLANS

If you are under a managed care plan, coverage of your services will be explained to you on your first visit. Please inform the receptionist of your employer so that we may contact the proper insurance and educate you of your insurance benefits regarding chiropractic care.

You are asked to authorize this chiropractic clinic to furnish information regarding your case to your insurance company and to assign all benefits as a result of the claim. This permits us to follow-up if benefits are other than anticipated. It also permits us to keep abreast of recent developments with local insurance companies, which enables us to continue to provide you with the most up-to-date information available.