Rose Family Chiropractic Wellness Center New Patient Forms
Please use the links to the left to print and fill out our insurance coverage and patient health history forms. The forms are in the PDF format; in order to view them you will need a PDF viewer such as Adobe Reader. If you do not have Adobe Reader you can click on the button below to download it FREE. 
Insurance and Payment Information
We attempt to take out as much of the “insurance hassle” as possible for you. We’ll happily telephone your insurance company to verify your coverage benefits. Please remember, however, that the benefits quoted to us by your insurance company are not a guarantee of payment. We will file your claim and await payment for 90 days. If your company pays the benefits they quote to us, the only services you will be responsible for are any non-covered services, deductibles or co-pays. If you have any questions at all regarding you financial responsibilities at our office, please do not hesitate to ask. Our insurance clerk has years of experience and will be happy to assist you.
PATIENTS WITHOUT INSURANCE
An increasing number of patients do not have insurance, or have plans with limited coverage, such as catastrophic policies. We realize that no one wants to build up a large bill. Therefore, we have several plans so those patients may receive complete care without undue financial difficulty. Of course we are always happy to accept cash, your personal check, MasterCard, Visa or Discover cards.
PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
Please notify your auto insurance carrier of your visit to our office immediately. Notify our insurance department immediately if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately.
MEDICARE
We do accept Medicare patients, but we do not accept assignment. The patient is responsible for payment at the time services are rendered and will receive reimbursement from Medicare for covered services. Medicare ONLY covers manual manipulation of the spine. Our office completes and files the forms for Medicare at no charge.
SECONDARY INSURANCE
Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.
We are so happy to have you as a new patient and are looking forward to providing the high quality chiropractic adjustment, massage therapy and therapeutic exercise that will help you feel your best. If you have any questions, please call us at (830) 629-3101.