New Patient Welcome Form

Salama Chiropractic Center

APPOINTMENT INFORMATION

PATIENT INFORMATION

IN CASE OF EMERGENCY CONTACT


ACCIDENT INFORMATION


HEALTH INSURANCE INFORMATION

If “Yes”, then please fill in the the form fields below.

FINANCIAL RESPONSIBILITY

I understand that insurance billing is a service provided as a courtesy and that I am at all times financially responsible to Salama Chiropractic Center and/or its affiliated entities for any charges not covered by health care benefits. It is my responsibility to notify Salama Chiropractic Center of any changes in my health care coverage. In some cases exact insurance benefits can not be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by Salama Chiropractic Center and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form that I am accepting financial responsibility as explained above for all payment for medical services and/or supplies received.

ASSIGNMENT OF BENEFITS

I authorize direct remittance of payment of all insurance benefits, including Medicare, if I am a Medicare beneficiary, to Salama Chiropractic Center for all covered medical services and supplies provided to me during all courses of treatment and care provided by Salama Chiropractic Center and/or its affiliated entities or otherwise at its direction. I understand and agree this Assignment of Benefits will have continuing effect for so long as I am being treated or cared for by Salama Chiropractic Center, and will constitute a continuing authorization, maintained on file with Salama Chiropractic Center, which will authorize and allow for direct payment to Salama Chiropractic Center of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies and/or care provided to me by Salama Chiropractic Center.

The above-named doctor may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.