Non-Covered Services: Financial Disclosure Form 2013
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1Non-Covered Services: Financial Disclosure Form
Provider Name: _______________________________
Address: ____________________________ City: ____________________________ State: ________ Zip: _________
Phone Number: (______) __________________
As your Doctor of Chiropractic, I want to provide you with the best care possible. While your policy covers some chiropractic services, there
may be others that I feel would help the treatment of your condition and maintenance of good health, but are not covered by your health
insurance coverage. If you agree to receive these services, and they are later determined to not be eligible for reimbursement through your
health plan policy, your signature on this form signifies your agreement to pay for them in full. While you may choose to not obtain these
services, I want to reassure you that I will only recommend care that I believe will benefit your health.
Chiropractic services typically covered by health insurance policies include:
Chiropractic manipulations to treat a clinical condition
Treatment that has the potential to significantly improve a clinical condition
Limited treatment of symptom flare-ups or exacerbations where a permanent condition exists.
Services that we expect to not be eligible for reimbursement through your plan’s chiropractic benefit, and therefore will likely be your
financial responsibility should you elect to receive them, are outlined below. Your financial responsibility is limited to services received
during the treatment plan as defined below:
Treatment plan start date: ____________________
Treatment plan end date: _______________________
Note: The defined treatment plan can not be more than 12 weeks long
Member
Non-Covered Service
Cost Per Visit*
Initials/Date
Exam(s)
Manipulation
X-ray(s)
Therapies/Modalities (Circle All Applicable Therapies)
Electrical Stimulation
Acupuncture
Other: ________________________
Ultrasound
Exercise Education
Durable Medical Equipment (Circle All Applicable Products)
Braces
Orthotics
Ice Pack
Other:_______________________________________________
Massage
Other:
Total:
*Patient’s billed amount may not exceed the provider’s usual and customary amount
I believe these services will not be eligible for reimbursement through your health plan because (check one):
They are maintenance or elective care rather than treatment to improve a clinical condition
They are excluded from your chiropractic coverage, even when related to treatment to improve a clinical condition
Provider/Authorized Health Care Representative Signature:_____________________________________________Date:_____________________
I acknowledge that I am signing this statement voluntarily, and that it is not being signed after the services have already been provided. I
have had ample opportunity to ask questions about my liability and the provider/staff has answered them to my satisfaction. I understand
that I have the right to refuse this care and that by signing this form I will be fully responsible for the total billed charge(s) related to non
covered services.
______________________________________________________________
Date: ___________________
Patient’s Name
_____________________________________________________________
Patient or Authorized Representative Signature
A copy of this signed form must be provided to the patient upon request
Chiropractic Care of Minnesota, Inc.
Rev. 10/28/13
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