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  • 56 Winthrop Street
  • Concord, MA 01742
  • 978 369 2266
  • www.drrobichaud.com
  • BLUE CROSS BLUE SHIELD WAIVER FORM:

  • Dr. Robichaud is a participating provider in the BCBSMA program. We will take a copy of your card and submit your claims to BCBS 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.
  • BCBS 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 BCBS, and you will be responsible for paying for these personally. The standard chiropractic benefit under BCBS 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.
  • 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:
     - -
  • Should be Empty: