Chiropractic Clinic West
CHIROPRACTIC CARE BENEFITS
For your convenience we have installed our initial visit office paperwork. If you are a new patient to our office please download, print and complete the New Patient Information, the Welcome paperwork found in Downloads one and two, the Waiver for Release of Information, and the Insurance Procedures download. If you are seeking care for a automobile or work comp injury, please download, print, and complete that paperwork as well as the forms outlined above. If you are a Health New England subscriber not employed by Baystate Medical Systems, please download and complete the ACN paperwork. Please bring your completed paperwork our office at the time of your first visit. Thank YOU! We look forward to meeting you soon.
New Patient Information
Information about you
Health History Form - 2 pages
Waiver for Information
This waiver will allow our staff to collect pertinent information in advance of your first appointment for the doctor to review.
We will gladly submit your insurance claims if you have chiropractic coverage and we participate in that plan. Please download, print, and compete the form. Please call your insurance company to verify coverage before you make your first appointment.
Auto questionnaire. Please also supply us with information at the bottom of the form regarding your insurance company, address, telephone, and contact person. If you have retained an attorney, please also note their name, address, and phone.
Worker's Compensation Questionnaire needs to be printed and filled out prior to your first appointment.
Health New England Subscribers who are not employed and insured by Bays Medical Systems need to download, print, and complete the three page ACN health questionnaire prior to their first visit.
Advanced Beneficiary Notice (ABN)