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Patient Forms

Please use the following link to print and fill out our patient health history forms before your scheduled appointment time. You will not have time to fill the forms out in the office when you arrive.

The forms are in the PDF format; in order to view them you will need a PDF viewer such as Adobe Reader.

Chiropractic New Patient Paperwork

Adult Patients: These will be the only history forms you need to bring with you, a total of four (4) pages!

For children (up to the age of 17), the following form is the ONLY one necessary:

Child Chiropractic Paperwork

For Acupuncture, the following paperwork will need to be filled out regardless of age. Please fill out before your scheduled appointment time.

Acupuncture New Patient Paperwork

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, IU Health, Encore, IHN and more!

**We are also providers for Medicaid and Medicare**

PATIENTS WITHOUT INSURANCE
An increasing number of patients who have plans with limited coverage, such as high deductible or catastrophic policies. We realize that no one wants to build up a large bill. Adjustments are only Please feel free to ask Linda about a CareCredit.  Of course we are always happy to accept cash, your personal check, MasterCard, Visa or Discover cards.

PERSONAL INJURY OR AUTOMOBILE ACCIDENTS

We will not take assignment on any Personal Injury or Workman’s Compensation case. You are welcome to pay our cash rates for each visit and then submit them to any insurance company or attorney for reimbursement. We will assist you in providing notes for your care and invoices showing your payment.

MEDICARE
We 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. An initial examination, x-rays, and any physical therapy is NOT covered.  Be aware that a deductible applies 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.

Vaccination Exemption Form for Indiana

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