Please use the following links to print and fill out our  patient health history forms. The forms are formatted in Adobe Acrobat, in order to view them you will need Adobe Acrobat Reader installed on your computer. If you do not have Adobe Acrobat Reader you can click the link below to download it FREE.

                                                                     http://get.adobe.com/reader/

 

                                                          

                                                                      New Patient Forms

                                                                

                                                                                                                                                                                           

                                                      

GROUP OR INDIVIDUAL INSURANCE
     We attempt to take out as much of the "insurance hassle" as possible for you. We'll happily telephone your insurance company to verify your coverage benefits. Please remember, however, that the benefits quoted to us by your insurance company are not a guarantee of payment. We will file your claim and await payment for 60 days. If your company pays the benefits they quote to us, the only services you will be responsible for are any non-covered services, deductibles or co-pays. If you have any questions at all regarding you financial responsibilities at our office, please do not hesitate to ask. Our insurance clerk will be happy to assist you.

 

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

 

"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
     Please notify your auto insurance carrier of your visit to our office immediately. Notify our insurance department immediately if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after your care is completed. 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 deductible has been met. You are required to pay the deductible and the remaining 20% as well as any non-covered services. Our office completes and files the forms for Medicare at no charge.

 

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