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Forms


The forms below can be printed and filled out prior to your visit to save you time.  If you don't have Adobe® Reader®, please click the button below to download it at no cost.  This is required to open the forms.

New Patient Form
Ages 5+.  This form is for all adults and children five years of age or older.  No printer required. 
All new patients of that age must fill this form out in order to receive any services.  A paper version of this form is below or available in office; please arrive 30 minutes before your appointment time in this case.


Pediatric New Patient Form
Ages 0-5.  This form is for all pediatric patients younger than five years of age.  No printer required. 
All new patients of that age must fill this form out in order to receive any services.  A paper version of this form is below or available in office; please arrive 30 minutes before your appointment time in this case.


Current Patient Update Form
Some patients may be asked by the office to fill out the reactivation form. This may be if it's been more than six months since your last treatment and/or if you may have a new diagnosis.
Patients being reactivated must fill this form out in order to receive any services.  A paper version of this form is available in office; please arrive 10 minutes before your appointment time in this case.


New Patient Form (Paper Alternative)
This form requires a printer.  Only use this form if you cannot use the above forms.  This form can be used for patients of any age.

Massage Form
Please fill this form out if you will be receiving a massage in our office or if you would like to be considered for massage.

ABN Form (Medicare Only)
This "Advanced Beneficiary Notification" form is for all Medicare patients.  This form tends to be confusing so please feel free to fill this out in office and we will gladly go over this.



ABOUT PAYMENT AND INSURANCE:

GROUP OR INDIVIDUAL INSURANCE

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 Care Credit Cards.  (New Health Care Financing Available via Care Credit®).

WORKERS' COMPENSATION
If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has not been made within 3 months, or if you suspend or terminate care, any fees and services are due immediately.

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 assignment from Medicare. The check is usually sent directly to our office in payment of the services that Medicare will cover, which for Chiropractors is ONLY manual manipulation of the spine. Medicare pays 80% of the allowable fee once the 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.

SECONDARY INSURANCE
Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.




 
 

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Shiloh Chiropractic | 1231 Frank Scott Pkwy E # 100 | Shiloh, IL 62269 | (618) 234-8300