STEP ONE: Click the following link to print and fill out our financial, massage, HIPPA, and communication forms:

PATIENT FORMS

STEP TWO:  If you're filling out a form for someone who is 14 YEARS OF AGE OR OLDER, click the following link to fill out our online intake form. You do not need to print this form. If you're filling out paperwork for a child who is newborn-13 years of age, please print and fill out the age appropriate form rather than filling out and submitting the intake form.

INTAKE FORM

or....

If you're filling out paperwork for a child, please choose the link with the appropriate age, print, and fill out.

Newborn – 2 Months
2 Months – 2 Years
3 Years – 5 Years
6 Years – 13 Years

Optional Step:

The following link is our privacy practices.  It is for viewing if you so desire.  It does not need to be printed.

Privacy Practices

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.

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. Of course we are always happy to accept cash, your personal check, MasterCard, Visa or Discover cards.

CARE CREDIT
It is important to be able to schedule treatment and care right away. That's why we offer CareCredit, a healthhcare credit card specifically designed to pay for treatments and procedures not covered by insurance. CareCredit has two unique features. Every CareCredit transaction is eligible for a No Interest (if paid within promotional period) or Low Fixed Interest Payment Plan -- and, you can use the card at all healthcare practices that offer CareCredit. As the leader in patient financing, CareCredit has made it easy for millions of patients nationwide to get the treatment they want and need. Click the button below to learn more and apply for a CareCredit account!

"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 directly to our office in payment of the services that Medicare will cover, which for Chiropractors is ONLY manual manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has been met. You are required to pay the deductible and the remaining 20% as well as any non-covered services. 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.