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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)

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
Insurance/Subscriber ID # *
保険のID番号
Your answer
Subscriber Name *
保険の契約者名
Your answer
Medicare ID number (If you do have one)
老人保健の番号
Your answer
Relation to the subscriber *
保険契約者との関係(自分自身、配偶者、子供)
Is this a Workers Compensation (Work related injury that your company will pay for)? *
労働災害ケースですか?
Required
Is this an Auto Accident *
交通事故ですか?
Required
Preferred language *
ご希望される言語
Required
Preferred Contact Method *
ご希望される連絡方法
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): $120 and up
●Regular treatment (再診料): $70 and up

● Each insurance plan has a different coverage and policy
● We do not accept Medi-Cal or Medicaid

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