Forms & Insurance

Print forms for your visit and learn about accepted insurance, Medicare and payment options.


Patient Forms

Click on the links to print and fill out the forms below prior to your appointment.

For all new patients:

Complete if you have job-related injuries:

Complete if you've been in a motor vehicle accident:

  • Motor Vehicle Accident Form


    If you’ve been injured on the job or due to negligence you likely need a personal injury lawyer to help you get the compensation to which you are entitled. After an accident, people are often confused as to who will pay for treatment and what types of treatment they are entitled to receive. You’re entitled to have all reasonable treatment paid by the responsible party or their insurance carrier and for that, we recommend VanDerGinst Law. 

    VanDerGinst Law has represented thousands of injury victims and has recovered hundreds of millions of dollars on their behalf. We confidently refer our patients to VanDerGinst Law to handle their injury cases. When you contact them, mention our name to receive a discount on attorney fees. Speaking of attorney fees, VanDerGinst Law never charges an attorney fee on an injury cases unless they win. Contact them at 800-960-8529 (VLAW) or at

Insurance Coverage


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 your 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.


An increasing number of patients do not have insurance or have plans with limited coverage, such as catastrophic policies. Because we realize that no one wants to build up a large bill, we offer several plans to help you receive complete care without undue financial difficulty. Of course we are always happy to accept cash, your personal check, MasterCard, Visa or Discover cards.

ON-THE-JOB INJURY (Workers’ Compensation)

If you're injured on the job, your care should be paid for under your employer’s Workers' Compensation insurance. You'll need to inform your employer of the accident and obtain the name and address of their insurance carrier. If your employer does not provide us with this information, if a settlement has not been made within three months, or if you suspend or terminate care, any fees for services are due immediately.


If your condition is related to a motor vehicle accident, notify your auto insurance carrier of your visit to our office immediately. Also, notify our insurance department immediately if an attorney is representing you. Although you are ultimately responsible for your bill, we'll 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.

I wish I would have known years ago how important chiropractic care is for automobile injuries.
— Tim


We do accept assignment from Medicare. For chiropractic care, Medicare ONLY covers manual manipulation of the spine, and the check is usually sent directly to our office. Medicare pays 80% of the allowable fee once your deductible has been met. You are required to pay the deductible and the remaining 20%, as well as any non-covered services. Our office completes and files the forms for Medicare at no charge.


Please inform us of any secondary insurance you may have. We'll assist you if you need help in filing.