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Insurance Verification Request Form
This is for CHIROPRACTIC ONLY
保険のカバーを調べて欲しい方へ
(※カイロプラクティックの治療のみ)
* Required
How did you hear about us?
*
どのようにして当院を知りましたか？
Family
Friends
Doctor
Insurance
Employer
Yelp
Google
Magazine
Walk-in
Other:
Required
Last Name
*
苗字
Your answer
First Name
*
お名前
Your answer
Birth Date (MM/DD/YYYY)
*
生年月日 (西暦 月/日/年)
Your answer
Email address
*
Your answer
Cell Phone Number
*
携帯番号
Your answer
Health Insurance Name
*
保険会社の名前
Your answer
Insurance Plan
*
保険のタイプ
PPO
HMO
EPO
Discount
I dont know
Other:
Insurance/Subscriber ID #
*
保険のID番号
Your answer
Is this a Workers Compensation case(Work related injury that your company will pay for)?
*
労働災害ケースですか?
Yes
No
Other:
Required
Is this an Auto Accident
*
交通事故ですか?
Yes
No
Other:
Required
Preferred language
*
ご希望される言語
English
Japanese
Other:
Required
Preferred Contact Method
*
ご希望される連絡方法
Email
Text messege
Phone Call
Other:
Required
Notice
*We can verify your insurance coverage; however we cannot guarantee the coverage.
保険のカバーをお調べすることは可能ですが、保証はできません。
* Please remember that text messaging may not be 100% secure.
Fee Schedule
Without insurance coverage
●First visit (初診料): $150 and up
●Regular treatment (再診料): $80 and up
● Each insurance plan has a different coverage and policy
● We do not accept Medi-Cal or Medicaid
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