56 Winthrop Street
Concord, MA 01742
978 369 2266
www.drrobichaud.com
OUT OF NETWORK WAIVER FORM:
Dr. Robichaud is not a participating provider in your health insurance network.
We will take a copy of your insurance card and submit all your claims electronically to your insurance company for processing as a courtesy. This will allow a formal Explanation of Benefits to be generated, which is often required to use your Health Savings Account for payment of non-covered medical expenses. You will be responsible for payment of the difference between our submitted charge and whatever your insurance company might pay (if anything).
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.
The 2026 fee schedule is as follows:
New patient physical examination: $200.00
Established patient re-examination: $125.00
Back
Next
Spinal Manipulation (office visit):
$60.00
Manual soft tissue therapy:
$5.00
Applied 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.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Continue
Continue
Should be Empty: