New Patient Paperwork
Discover Chiropractic and Wellness offers our patient form(s) online so they can be completed in the convenience of your own home or office.
- All forms are editable PDF files. You will need AdobeReader® to view them.
- If you do not already have AdobeReader® installed on your computer,
Click Here to download.
- Download and save the necessary form(s), Fill them in and print them.
- E-mail us your printed and completed form(s) to email@example.com or bring them with you to your appointment.
Our goal is to make your care effective and affordable. We have several payment plans available for our patients with no or limited insurance coverage. Insurance payments for chiropractic care vary tremendously from insurance company to insurance company and even from policy to policy. We ask that you read and understand our policy as it applies to your particular situation.
PATIENTS WITHOUT INSURANCE OR PATIENTS WITH INSURANCE THAT EXCLUDES CHIROPRACTIC
We request that 100% of the first visit be paid at the time of the visit. On other visits, payment may be made at the end of the week if you sign a credit guarantee form. We are happy to accept your check, Master Card, Discover or Visa. Many of our patients pay for their care using our Healthcare Made Affordable Plans.
GROUP OR INDIVIDUAL INSURANCE
When possible, we will call to verify 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. Your insurance is an agreement between you and your insurance company, not between your insurance company and our office. We cannot be certain if your insurance covers Chiropractic, although most policies do provide coverage. The amount they pay varies from one policy to another. As a courtesy to you, our office will complete any necessary insurance forms at no additional charge, and file them with your insurance company to help you collect. If you receive any correspondence from your insurance carrier pertaining to the care you have received at this office or a request of more information regarding your care, please bring is in as soon as possible. Occasionally, either by mistake, or due to provisions in your policy, the check issued by the insurance company for payment of services rendered in our office, may come to you instead of our office. If you should receive any unexpected check in the mail, please contact us to see if it does represent payment of your bill here.
You must notify your auto insurance carrier of your accident and on your first visit provide us with the claim number, adjustor’s name and phone number.
There are three options available to the PI patient:
- If you have Personal Injury Protection (PIP) we will bill (accept assignment) from the Personal Injury portion of your auto insurance.
- If you do not have Personal Injury Protection through your auto insurance then we will bill your standard health insurance plan and you will be responsible for all co-pays and deductibles as they are incurred.
- If you do not have Personal Injury Protection (PIP) You may pay cash for your care and we will submit reports whenever necessary to your 3rd party.
Once the claims are settled, or if you suspend or terminate care, any fees for services are due immediately.
We do not accept a Letter of Protection, Doctor’s Lien, or 3rd party claims.
We do not accept assignment from Medicare. You are required to pay for services as they are incurred. Medicare pays approx. 80% of the allowable fees once the deductible has been met. Medicare will send you the check directly for payment of the services that Medicare will cover. For chiropractic care, that is ONLY manual manipulation of the spine. Our office completes and files the forms for Medicare at no charge.
MANAGED CARE PLANS
We are providers for many managed care plans, including Blue Cross Blue Shield, Aetna, United Health Care, Humana, PHCS, and many others. Please call our insurance department so we can verify the chiropractic benefits of your plan.
8:00am - 12:00pm
8:00am - 5:00pm
8:00am - 5:00pm
8:00am - 12:00pm
Saturday & Sunday
Discover Chiropractic and Wellness
950 West University Avenue #103
Georgetown, TX 78626