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Name (First Name, Last Name)
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Birthdate (mm/dd/yyyy)
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Address (Street Address, City, State / Province, Postal / Zip Code)
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Phone Number
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Email Address
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Do you have health insurance?
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What health insurance do you have?
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Insurance information: (Include insurance name and member ID for all policies)
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Please note that we are only in network with Medicare and BCBS. If you have a Medicare Supplement or Replacement plan that is not BCBS, we can provide you with the receipts you'd need to be reimbursed.
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Have you previously seen a chiropractor?
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If so, for what reason did you last see them and when was it?
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Please describe your health status, including: (Recent visits to other doctors, hospital stays, motor vehicle accidents, surgeries, and/or any work related injuries:)
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Please list any supplements/medications you are taking:
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What is your reason for today's visit?
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Is there anything else you'd like for us to know?
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Depending on insurance coverage and services received, fees can vary.
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If Doctor requires x-rays, Medicare does not cover the cost of chiropractic x-rays (see form below)
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If a policy is subject to a deductible, the fee is $38.73 and it is due at time of service
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If a policy does not have coverage, patient will be subject to a cash fee charge and is responsible for all fees at time of service
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If you have a medicare replacement policy- we may be out of network and cash fees will apply.
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Advance Beneficiary Notice of Non- Coverage (ABN)
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Signature of consent to fees:
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By signing, I fully understand the above fees/statements and give my consent.
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