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  • 56 Winthrop Street
    Concord, MA 01742
  • 978 369 2266
  • www.drrobichaud.com
  • HARVARD PILGRIM WAIVER FORM:

  • Dr. Robichaud is a participating provider in the Harvard Pilgrim Health Plan. We will take a copy of your card and submit your claims to HPHC for processing and payment. Some plans carry a deductible and co-payment, which you will be responsible for paying.
  • We have a system in place to keep a form of payment on file in a secure platform to pay for any remainder balances that might be due after processing. You will be sent a receipt for any payments made to this stored card. If you prefer to receive a paper bill in the mail rather than have the remainder balance charged to a card, please let us know.
  • HPHC covers many of the services offered here, and we will charge you the difference between what they pay and what the plan allows. Some services are not covered by HPHC, and you will be responsible for paying for these personally. The standard chiropractic benefit under HPHC covers 12 office visits per year. They do not cover maintenance care. Should you exhaust your benefits, you will be responsible for paying the normal office charges for these services.
  • If you are a new patient entering the practice, Dr. Robichaud is required by law to perform a physical examination to establish a proper diagnosis and establish an appropriate plan of care. Typically, he will treat you on the same day if there is no contra-indication to do so. HPHC reduces the allowed rate for the physical examination if the patient is treated with
  • spinal manipulation on the same day. Dr. Robichaud is not willing to accept this lower fee, so you will be offered a choice. He can see you for the physical examination alone without treatment or he can treat you after the physical examination. If you choose to have treatment on the same day, there is an additional $40.00 charge.
  • The 2026 fee schedule is as follows:
  • New patient physical examination: $200.00
    Established patient re-examination: $125.00
    Spinal Manipulation (office visit): $60.00
    Attended physiotherapy: $20.00
    Stretching instruction: $20.00
    Exercise instruction: $20.00
    Manual soft tissue therapy: $5.00
    Unattended physiotherapy: $5.00
    Kinesiotaping: $5.00
  • I have read the waiver form and understand that I am responsible for payment of any remainder balances on my account.
  • Date:
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  • Should be Empty: