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Thank you for taking the time to print, fill-out and bring in your initial intake forms. Please select the HIPAA & Terms PDF, along with the appropriate age document. We look forward to seeing you soon!
HIPAA & Terms
For all Patients
Adult Intake Form
Age 5-16 Intake Form
Newborn-4 Intake Form
What can I expect?
Your first visit
During your first visit, we will begin by focusing on you and your personal needs and concerns. We will do this by discussing your current condition and/or symptoms and your health history, along with addressing any questions you may have. A detailed physical examination will then be performed. This exam will allow us to create a personalized treatment plan for you, which will be discussed at your second visit.
If your exam warrants x-rays, we will send you right down the road to Mosaic Life Care. They accept walk-ins and will return the report to us within 24 hours. These will be discussed on your second visit.
Your second visit
During your second visit, we will discuss the treatment plan that has been created for you. We will then proceed onto the first phase of your chiropractic care. We will begin with adjustments and possible therapies, if needed. Possible therapies might include: electrical stimulation (E-Stim), intersegmental traction, cryotherapy, and/or therapeutic exercise.
Insurance & Fees
We are only accepting United Healthcare and most Blue Cross Blue Shield Insurance at this time.
We accept cash, local checks and major credit cards, including American Express. If you have insurance that accepts out of network chiropractors, we will provide you with a detailed receipt (that has all of the elements that are required by most insurance companies in order to reimburse the insured) or “superbill“, so that you may get reimbursed by your insurance company.
What is a superbill?
A superbill is a form completed by medical practitioners that allows patients to be reimbursed directly from their health insurance companies.
A superbill does not guarantee that an insurance provider will pay for the services provided. Each insurance plan is different, and it is your responsibility to contact your insurance provider and find out exactly what will be covered.
Sending in your superbill for reimbursement
To ask your insurance company to reimburse you for services you received from your doctor, mail (or submit online, depending on the company) your insurance company the following:
The superbill you received from your doctor, and:
A photocopy of your insurance ID card, front and back (We can photocopy it for you if you bring it in).
Keep a photocopy of all the documents you send in for your records (We can give you two copies).
Why does my doctor not bill my insurance company for me?
Many insurance companies are not required to contract with doctors and so some of them choose not to. As a result, those doctors are considered out-of-network providers, meaning they do not work directly with insurance companies. Patients of chiropractors can pay out-of-pocket for services and submit a superbill to attempt to get reimbursed by their insurance plan.
Choosing instead to work as out-of-network provider ensures that your doctor makes medical decisions that are purely based on professional expertise and not on health insurance policies.
How do I find out what my insurance company will reimburse for an out-of-network provider?
Call the customer service phone number listed on your insurance card.
Ask, “I want to work with an out-of-network chiropractor. I would like to know how much will you reimburse me and what is the best way to submit my claim for reimbursement with a superbill?”
Be sure that your insurance plan benefits are clear to you such as: what should your health plan cover and what health services count toward your deductible?
Be aware that should you choose to submit a superbill; you are releasing medical information that is protected by law. This means you are waiving some of your rights to privacy and confidentiality. It is standard for your insurance company to keep a record of your diagnoses stated on the superbill as part of your permanent medical file.
Our cash price is a time of service discount. Payment must be made on the day of service to qualify. The intitial visit (consult, history, comprehensive examination and report of findings) is $75.00 per adult and $50.00 per child. If adjusted on the first day, an additional adjustment fee will be applied:
Adjustments (including necessary therapies) are $40.00 per adult and $25.00 per child age 16 years and younger.
*Military (with valid ID) and their spouse are only $30.00 per adjustment! This special price is thanking you for your service! Dr. Alison's home visits are different than the office charges.