Request edit access
New Patient Form
【Fee Schedule and Payment Policy for patients】

First Examination and Treatments or Re-Examination and Treatments
$160 and up

Regular treatment or visit
$85 and up

□ Fees may vary depending on the treatments provided.
□ Depending on your insurance policy, treatments may not be covered.
 If you have MediCal/Medicaid, please visit a Medical Certified Doctor.  We do not accept MediCal/Medicaid Insurance.
□ We do not accept lawyer involved lien cases. It will be self pay option. 


【INSURANCE】
Your health insurance may not cover chiropractic care.
If you would like to verify your health insurance coverage for chiropractic care, please use the verification form on the website.
※Please note that we cannot guarantee your insurance coverage and coverage may differ after sending the claim to the insurance company.

If you have any questions, please call/text/e-mail us.
Tel: (213) 617-2228
Email: info@bestclinicla.com
Sign in to Google to save your progress. Learn more
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Weebly Email Service. Report Abuse