Pediatric History Form (Page 6 of 6) in pdf

Pediatric History Form Page 6

Upper Valley Chiropractic

“A Family Health and Wellness Center”

107 S. Main St.

West Lebanon, NH 03784

Dear Patient:

Upon verifying your insurance coverage for Chiropractic Insurance, companies

occasionally give this office incorrect information. Therefore, we strongly urge you to

contact your insurance company to verify your own insurance.

Please verify the following information and return this form to Upper Valley

Chiropractic.

Following this procedure may prevent problems with billing and payments, therefore

preventing you from receiving an unexpected bill.

INSURANCE COMPANY___________________________

ID#_______________________

Customer Service Rep:____________________________________________________

Effective Date of Insurance:________________________________________________

Copay/Explanation of Benefits:_____________________________________________

Is a deductible required?__________________________________________________

Are X-rays covered if necessary?___________________________________________

Is there a referral needed before service? _____________________________________

Number of Visits Allowed: _________________ per

Contract or Calendar year?

Additional Information: __________________________________________________

Information Taken By: ________________________ Date: _____________________

Upper Valley Chiropractic, Dr. Amber L. McLelland, is in Network for: Blue Cross Blue

Shield (Anthem), Cigna and Harvard Pilgrim, United Health Care, Aetna, Health Care

Value Management, Great West

We are O ut of Network for: Medicaid

Pediatric History Form Page 6