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Welcome to Quantum Healing
Spiritual Women Leaders
Insurance
| Health Insurance Policy | | Print | |
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Use this questionaire to call your insurance company & find out exactly what they are contracted to cover. HEALTH INSURANCE CHIROPRACTIC POLICY PATIENT’S NAME (PLEASE PRINT) _____________________________________ 2. What is the DEDUCTIBLE? ______________________________________ When does the deductible start over? ________________________________ Has the deductible been paid? YES ____ NO ____ How much has been paid? ______________ 3. What PERCENTAGE of my bills will my policy cover? 4. What PERCENTAGE of massage therapy (97124) will my policy cover? 5. What PERCENTAGE of my x-rays will my policy cover? Are X-RAYS subject to the deductible? YES _____ NO _____ 6. What is the EFFECTIVE DATE of my policy? ________________ POLICY#:__________________ 7. Can BENEFITS BE ASSIGNED to my Chiropractor’s office? YES____ NO____ 8. What is the ADDRESS where the claims should be sent? NAME:_______________________________________________________ STREET:_____________________________________________________ CITY:________________________________________________________ 9. To whose ATTENTION should it be addressed?______________________ 10. PHONE NUMBER:_____________ Insurance Company Name:_________________ 11. POLICY TYPE: (circle) GROUP INDIVIDUAL 12. NAME POLICY IS UNDER: ___________________________________ SOCIAL SECURITY # of Policyholder: ___________________________ 13. Please circle that which applies to your case: Personal Injury Major Medical Worker’s Compensation |
