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 ___________________________________________ __________________________________________________________________________________________ __________________________________________________________________________ -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? _______ _________________________________________________________________________________ -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 _________________________________