Chiropractic Services Provided
- includes practice member history. This service is complimentary.
Examination (new patient or established patient)
- includes one of more of the following: thermography, surface electromyography, range of motion, motion and/or static palpation, leg check.
– The actual re-alignment of the vertebra. A specific instrument is used to make the spinal adjustment. 1 to 3 specific adjustments will be made per visit, re-aligning the vertebra.
– Specific x-ray views taken of your spine to determine a misalignment/subluxations of your vertebrae. These can also be used to indicate progress after period of care.
**All charges will be reviewed and authorized by practice member before any charges are rendered
Release of Authorization/Assignment of Benefits
I authorize the release of any information necessary to process my insurance claims. I authorize and request payment of insurance benefits directly to the doctors. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment.