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; you will need a PDF viewer such as Adobe Reader in order to view them. If you do not have Adobe Reader you can click the following button to download it FREE.

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PATIENTS WITH INSURANCE

Your insurance is an agreement between you and your insurance company, not between your insurance company and our office. We cannot be certain if your insurance covers Chiropractic, although most policies do provide coverage.  The amount they pay varies from one policy to another. 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. As a courtesy to you, our office will complete any necessary insurance forms at no additional charge. In order for our office to bill your insurance plan, you must sign a credit guarantee form. It is to be understood and agreed that any services rendered are charged to you directly and you are personally responsible for payment of any non-covered services, deductibles, co-pays or co-insurance. Refer to ‘Financial Policy for Patients with Health Insurance’ form.

PATIENTS WITHOUT INSURANCE

We request that 100% of the first visit be paid at the time of the visit.  On other visits, payment may be made at the end of the week if you sign a credit guarantee form.  We are happy to accept cash, your check, Master Card, Visa or Discover.

FLEX PLANS/HEALTH SAVINGS ACCOUNTS

Please inform us if you have a health savings account, sometimes known as a "Flex Plan".  We will be happy to provide you with a statement of your charges so you can be reimbursed.

PERSONAL INJURY OR AUTOMOBILE ACCIDENTS

Please present your auto insurance card, your health insurance card, accident claim number, and tell us if you have retained an attorney.  There are four options available for payment:

1.     Pay cash for your care and we will submit reports whenever necessary.

2.     We will bill (accept assignment) from the Med Pay portion of your auto insurance. 

3.     We will accept a Letter of Protection or Doctor’s Lien from an attorney and await payment at the time of settlement as long as you remain an active patient.

4.     We will bill your standard health insurance plan and you will be responsible for all co-pays and deductibles as they are incurred.

 Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to 6 months after your care is completed. In order for our office to bill your auto insurance plan, you must sign credit guarantee form. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately.

MEDICARE

We do accept assignment from Medicare.  The check is usually sent directly to our office in payment of the services that Medicare will cover; which for Chiropractors, is ONLY manual manipulation of the spine. Medicare pays 80% of the allowable fee once the Medicare deductible has been met.  You are required to pay the deductible and the remaining 20% co-insurance for each visit.  All other services we provide are NON-COVERED. These services include, but are not limited to, x-rays, examinations, therapies, orthotics, supports, and/or nutritional supplements.  Medicare patients are fully responsible for charges of non-covered services.  Secondary insurance may or may not pay for these non-covered services.  Our office completes and files the forms for Medicare at no charge. In order for our office to bill Medicare and your secondary insurance plan, you must sign credit guarantee form.

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SECONDARY INSURANCE
Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.