Vanderslice Family Chiropractic Insurance Form

 Please complete this form using your keyborard then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment. This form will not be submitted via the Internet, so security is not an issue.

The following questions are necessary so that we may properly file your insurance for you. These questions are taken directly from the insurance form that we must fill out and file for you. Please answer as completely as possible.

1. Type of insurance: Medicare      Medicaid      Champus       CampVA      Group Health Plan      Other

Insured’s ID Number

2. Patient Name:

  1. Insured's Name (as it appears on the insurance card):
  2. Patient's Address:

CityState Zip   Phone Number

5. Insured's Address (if same as patient put "same"):

CityState Zip   Phone Number

6. Patient Status: Single      Married      Other      Employed      Full-time Student      Part-time Student

7. Other Insured's Name (if applicable):

Other Insured's Policy or Group Number:

Other Insured's Date of Birth:  Male    Female

Employer's Name or School Name:

Insurance Plan Name or Program Name:

8. Is the condition we are treating related to current or previous employment? Yes    No

9. Is the condition we are treating related to an auto accident? Yes    No

10. Is the condition we are treating related to another type of accident? Yes    No

11. Insured's Policy Group or FECA Number:

Insured's Date of Birth: Male    Female

Employer Name or School Name:

Insurance Plan Name or Program Name:

12. Is there another health benefit plan? Yes     No

Patient's or Authorized Person's Signature: I authorize the release of any medical or other information necessary to process my insurance claim. This is to serve as a long-term authorization card.

Signed:         Date:

Insured's or Authorized Person's Signature: I authorize payment of medical benefits to for the services described on the insurance form. This authorization is to apply to all occasions of service until it is revoked in writing. I agree to pay for services not covered by insurance and understand that I am ultimately responsible for payment in full at this office.

Signed:         Date: