Forms

 

NEW PATIENTS MUST SCHEDULE AN APPOINTMENT AT LEAST ONE HOUR BEFORE CLOSE OF BUSINESS HOURS.

TO SAVE TIME ON YOUR VISIT, please find the forms that apply to your case and fill them out at home after you print them up. Do not forget to bring a copy of your insurance card, if you have insurance. It is the responsibility of the patients to verify that I am an in-network provider, and that they have required referrals in place. Payment is expected at time of service including any copay or deductibles.

 

MEDICARE patients including those with supplementary policies:  D’Oria Chiropractic is a non-participating Medicare provider. This means that the Medicare patient pays in full for their spinal adjustment at the time of service. If Medicare deems that the visit is “medically justified”, a portion of costs is reimbursed by Medicare and will be sent directly to the patient and in some cases, secondary insurance reimburses a portion of the rest of the cost after your deductible is met.  There will still be one other short form for you to fill out in the office. If you cannot print these out, they can be filled out at the office on your next visit, so please allow extra time. If you are a Medicare Patient please print out these forms. 

Click to Download Medicare Forms

For those who are NOT MEDICARE patients with or without insurance: Please check with your insurance company to be sure that I am listed as an in-network provider. I should be in-network for most* (but not all) plans with these companies: BCBS/Horizon, Independence, and Amerihealth.  Some plans may require a referral from your primary care provider-please check your policy. I can look this up for you ahead of time if you like-please call if you are unsure and in most cases I can tell you in advance of your visit.  If you do not have health insurance, please let me know and we can try to find a way for you to afford chiropractic care. My fees are already very low.

Non-Medicare Patient Forms

If you cannot print these out, they can be filled out at the office on your next visit, so please allow extra time.

The initial visit takes more time and involves going over your history and paperwork, and discussing a plan of care. Please allow extra time for your visit.