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Patient Forms

Please click the link below to fill out and print our health insurance coverage and patient history forms.


Patient Confidential

Neck and Low Back Disability

PAIN SCALE

(use this alternate link if the first Pain Scale does not work)

INDIVIDUAL OR GROUP INSURANCE
We want to spare you from insurance hassles as much as possible. Our staff will contact your insurance company to verify your insurance coverage. However, please take note that the coverage quoted to us by your insurance provider is not a guarantee of payment. We will handle claims and please expect 90 days for the payment. Once your insurance firm pays the benefits, you will only settle the payment for co-pays, deductibles and non-covered services. For more information about individual or group insurance, we are more than happy to discuss things with you at our office or answer your telephone call.

PATIENTS WITH NO INSURANCE
If you do not have insurance, we can still help you reduce your bill. We have plans available for those who don’t have insurance coverage but want to undergo complete chiropractic care. We know life has ups and downs, so we offer numerous payment options for you. We accept cash, personal checks, Discover, Visa Card and MasterCard.

‘ON THE JOB’ INJURY COMPENSATION
For workers who got injured at the workplace or on the job, your treatment will be shouldered by your employer’s insurance provider. Let your employer know about the accident and get the name and address of the insurance company. Without the information presented or no agreement made within 3 months, any fees are due immediately.

AUTOMOBILE ACCIDENTS OR PERSONAL INJURY COVERAGE
Please inform your insurance company prior to visiting us for your treatment. Coordinate with our insurance department right away if you have a representative lawyer. Although you are solely liable for your payments, we give six months grace period for the settlement of your insurance claim. When the claim is settled or if you terminate or suspend care, any fees are due immediately.

MEDICARE
We accept Medicare patients. We usually receive the payment check directly in our office. However, keep in mind that it is ONLY for the manual chiropractic treatment of the spine. Medicare shoulders 80 percent of the fee once the deductible is settled. The patient will settle the remaining 20 percent and other non-covered services.

SECONDARY INSURANCE
Don’t hesitate to inform us if you have secondary insurance. We can give you a hand in filing in to streamline the process.

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