PLEASE CALL THE CUSTOMER SERVICE NUMBER ON THE BACK OF YOUR INSURANCE CARD TO ANSWER THE QUESTIONS BELOW:
**Please note if your primary insurance is Medicare, you do not need to fill out this form
"Hello, my name is _____ and I would like information on my chiropractic benefits"
(Please note that we bill as 'office')
I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge.
I consent to the collection and use of the above information to this office. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I consent the office staff and doctors to use my contact information for the purpose of appointment reminders and any necessary annoucements.
I understand that like any and all medication procedures, there are risks. These include but are not limited to, fractures, disc injurieres, strokes, dislocations, sprains. I do not expect the doctor to be able to anticipate all risks and complications and I wish to rely on the doctor to exercise judgememt during the course of the procedure that is in my best interest.
I understand that there is no guarantee of results. It is understood that every patient is unique and can be affected by treatment in different ways.
I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for payment at time of service. I will secure my account with a credit card on file. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment with the secured credit card on my account.
The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation as deemed necessary by the doctor.