USE THIS FORM TO VERIFY COVERAGE FOR CHIROPRACTIC CARE: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient’s Name and Subscriber’s Name in the designated fields. This information is crucial for identifying the insurance coverage.
Indicate the Relationship to Patient, Insurance Company, and provide the Insurance Phone Number. These details help streamline communication with your insurance provider.
Fill in the Date and Time of your call, along with the Name of the Insurance Representative you spoke with. This documentation can be helpful for future reference.
Proceed to answer the questions regarding your coverage. For each question, select 'Yes' or 'No' as applicable, and fill in any amounts where indicated (e.g., co-pays, deductibles).
Complete any additional questions about therapy coverage and limits. Ensure all fields are filled accurately to avoid delays in processing.
Finally, sign and date the form at the bottom before submitting it back to our office by your second visit.

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