Insurance / Cash Paperwork

Patient Data Form (front)

Patient Data Form (back)

Assignment of Benefits

Informed Consent

Neck Index (fill out for neck/shoulder/arm pain)

Back Index (fill out for back/hip/leg pain)

 

Minor Paperwork – all of the above plus the following form

Consent to Treat a Minor

 

Auto Accident Paperwork

Automobile Accident Questionnaire (front)

Automobile Accident Questionnaire (back)

Assignment of Benefits

Informed Consent

HIPPA

Neck Index (fill out for neck/shoulder/arm pain)

Back Index (fill out for back/hip/leg pain)

 

Work-related Injury Paperwork

Worker’s Compensation Questionnaire (front)

Worker’s Compensation Questionnaire (back)

Assignment of Benefits

Informed Consent

HIPPA

Neck Index (fill out for neck/shoulder/arm pain)

Back Index (fill out for back/hip/leg pain)