Patient History Forms
Please click on the History Form you want to download. Print the form, fill it out, and bring to our office for your visit.
Please click on the Outcome Assessment you want to download. Print the form, fill it out, and bring it to our offices for your next Exam appointment.
Financial Policy: Your health goals are our number one priority, and we pledge to provide you with high quality, personalized and effective care. We also strive to make your care affordable. Whether you are paying fully out of pocket or have insurance that covers part of your care, our staff is prepared to answer your questions and assist you in regaining and maintaining your health.
SELF PAY: Most patients who do not have insurance take advantage of our cost saving Care Plan, which will be explained to you. Otherwise, payment may be made at the time of service, or you may choose to sign up for Care Credit, a no-interest payment plan for up to six months. We also accept cash, check, Master Card, Visa, Discover, or American Express.
MANAGED CARE PLANS, OR INDIVIDUAL INSURANCE: We are providers for many chiropractic insurance plans. Please call our office to see if your insurance policy is accepted. We make every attempt to verify accurate benefits on your insurance. However, the benefits quoted to us by your insurance company are not a guarantee of payment. Payment will be due by you at the time of service for any non-covered services, deductibles or co-pays. Maintenance care is not covered by insurance policies.
MEDICARE FOR CHIROPRACTIC: You can be confident we strictly adhere to Medicare’s Allowable Charges for our ‘65 and Better patients for all services. We do not accept assignment from Medicare. You are required to pay for services as they are incurred. Medicare will pay up to 80% of the Allowable Charge on manual manipulation they consider to be ‘Medically Necessary’ once any deductible has been met. Medicare will send the check directly to you in payment of manual manipulation of the spine ONLY. All other services in a chiropractor’s office are currently not covered under the Texas Medicare system. Our office completes and files the forms for Medicare at no charge. Maintenance care is not covered by Medicare.
PERSONAL INJURY OR AUTOMOBILE ACCIDENTS: Please notify your auto insurance carrier of your visit to our office immediately. Although you are ultimately responsible for your bill, we will submit any claims to your auto insurances’ Personal Injury Protection. We cannot submit claims through a third party. Notify our insurance department immediately if an attorney is representing you. We require a credit card on file in order to file any claims with your insurance company.
MAINTENANCE: is not covered by insurance. Most of our maintenance patients choose one of our cost-effective Care Plans. Or you can choose to pay at the time of each service with cash, check, Visa, MasterCard, Discover, or American Express.