Form Cms-R-131 - Application For Peripheral Neuropathy Treatment Page 9
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10CASH ADVANCE BENEFITS NOTICE
Patient’s Name:
DOB
SSN
State
Zip
Address
,
Additional Notes:
Doctor or Therapist
Charge for
General Services
Description
Services*
Manipulation of any of the five spinal areas: Cervical, Thoracic,
Spinal Adjustments
Lumbar, Sacral and Pelvic regions.
$45 to $55
Other areas of adjustment including Head, Face,TMJ, Upper
Extremity (Shoulder, Upper Arm, Elbow, Lower Arm, Wrist,
Non Spinal/Extremity
Hand, Finger), Lower Extremities (Thigh,Knee, Lower Leg,
Adjustment
Ankle, Foot, Toe), Ribs and Abdomen.
$25
Can include Trigger Point Therapy, Manual Traction, Myofascial
Manual Therapy
Release, Manipulation/Mobilization per 15 mins.
$30
Massage Therapy
Methodical Pressure, Friction, Kneading of the body per 15 min.
$25
Can include patient history, testing, evaluations, consultations for
Patient Evaluations
new or continuing patients.
$25 to $150
Electromyography measures muscle contraction to help
Surface EMG Exam
determine treatment
$50
Vibration, Heat, UBE, Therapeutic Exercises, Neuromuscular
Modalities
Re-Education, Warm or Cold Ear Calorics
$10 to $90
Additional Services
See Front Desk
See Front Desk
I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for
payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will
immediately be due and payable. I authorize the release of any medical or other information necessary to process my insurance claim
if needed. I also understand I am responsible for any non-covered services from my insurance carrier when applicable. This is to serve
as a long-term authorization card. I authorize payment of medical benefits to Prax Chiropractic if applicable for the services
described on the insurance form that may be filed. This authorization is to apply to all occasions of service until it is revoked in
writing.
I have read this agreement and agree to abide by it in full.
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