Patient Forms
Please use the following links to print and fill out our patient health history forms. The forms are in the PDF format; in order to view them you will need a PDF viewer such as Adobe Reader.
Adult Patients: These will be the only forms you need to bring with you, a total of five (5) pages!
For children (up to the age of 17), the following form is the ONLY one necessary:
GROUP OR INDIVIDUAL INSURANCE
We attempt to take out as much of the “insurance hassle” as possible for you. We’ll happily telephone your insurance company to verify your coverage benefits. Please remember, however, that the benefits quoted to us by your insurance company are not a guarantee of payment. We will file your claim and await payment for 90 days. If your company pays the benefits they quote to us, the only services you will be responsible for are any non-covered services, deductibles or co-pays. If you have any questions at all regarding you financial responsibilities at our office, please do not hesitate to ask. Our insurance clerk has years of experience and will be happy to assist you.
We are currently providers for the following Insurance Companies:
Blue Cross/Blue Shield, Aetna, Cigna, UHC, Sagamore, HSM, Advantage, Encore, IHN and more!
**We are also providers for Medicaid and Medicare**
PATIENTS WITHOUT INSURANCE
An increasing number of patients do not have insurance, or have plans with limited coverage, such as catastrophic policies. We realize that no one wants to build up a large bill. Therefore, we have several plans so those patients may receive complete care without undue financial difficulty. Please feel free to ask Linda about a payment plan. Of course we are always happy to accept cash, your personal check, MasterCard, Visa or Discover cards.
“ON THE JOB” INJURY (Worker’s Compensation)
If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has not been made within 3 months, or if you suspend or terminate care, any fees and services are due immediately.
PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
Please notify your auto insurance carrier of your visit to our office immediately. Notify our insurance department immediately if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately.
MEDICARE
We do accept assignment from Medicare. The check is usually sent to us in payment of the services that Medicare will cover, which for Chiropractors is ONLY manual manipulation of the spine. Be aware that a $150 deductible for all Medicare patients. After the deductible has been met, Medicare pays 80% of the allowable fee leaving 20% to be paid by you or your supplemental insurance. If a balance is due, you are required to pay for care at the time of service. Our office completes and files the forms for Medicare at no charge.
SECONDARY INSURANCE
Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.
Other Medical Forms:
VACCINATION EXEMPTION FORM
This form is an example of what can be used in the state of Indiana as an exemption form for vaccination.
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