Dr. John Hilpisch
8995 Highway 5
Lake Elmo, Minnesota 55042
www.hilpischchiro.com
651-748-5731
HERE IS WHAT YOU CAN DO TO VERIFY
COVERAGE FOR CHIROPRACTIC CARE
(PLEASE FILL OUT AND RETURN ON YOUR NEXT VISIT)
VERY IMPORTANT-OUR OFFICE IS CONSIDERED A NON-PROVIDER
CALL YOUR INSURANCE COMPANY AND ASK THE FOLLOWING QUESTIONS:
-DOES MY POLICY COVER CHIROPRACTIC? _____ YES _____ NO
-IF YES, ARE THERE ANY LIMITS TO MY COVERAGE? _____ YES _____ NO
-WHAT ARE THOSE LIMITS? BE SPECIFIC ___________________________________________
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-ARE THERE ANY LIMITS TO THE NUMBER OF VISITS ALLOWED? _____ YES _____NO
-WHAT IS THE DEDUCTIBLE? _______ IS THAT YEARLY? _______
-HAS IT BEEN MET? _______ IF YES, HOW MUCH? _____________________________
-WHAT PERCENTAGE OF MY BILLS WILL MY POLICY COVER? _______________________
-WHAT IS THE EFFECTIVE DATE OF MY POLICY? ____________________________________
-CAN BENEFITS BE ASSIGNED TO MY CHIROPRACTIC OFFICE? _______________________
-WHAT IS THE ADDRESS OF THE OFFICE WHERE THE CLAIMS ARE TO BE SENT? _______
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-TO WHOSE ATTENTION IS THE CLAIM SENT? _________________________
-PHONE NUMBER OF INSURANCE COMPANY __________________________
-POLICY # _________________________ GROUP # ____________ INDIVIDUAL ____ JOINT___
-GROUP POLICY ______ YES _____ NO
-NAME POLICY IS UNDER ___________________________
-POLICY HOLDERS DATE OF BIRTH ________________
-NAME OF PERSON YOU SPOKE WITH ________________________
-YOUR NAME _________________________________