Insurance Verification Request Form

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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)

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

Subscriber Name *

保険の契約者名

Your answer

Relation to the subscriber *

保険契約者との関係(自分自身、配偶者、子供)

Self

Spouse

Child

Other:

Is this a Workers Compensation (Work related injury that your company will pay for)? *

労働災害ケースですか?

Yes

Other:

Required

Is this an Auto Accident *

交通事故ですか?

Yes

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

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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