Galloway Chiropractic New Patient Forms

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      Pain Questionnaire

      Total: __________ (staff member)

      10 being greatest stress

      A non-refundable $50.00 deposit is required to hold your new patient appointment with the doctor. Your deposit will be applied to the fees of your new patient visit and any subsequent visits if a credit is established after any copays, co-insurances, or allowed amounts.

      Payment can be made by check, cash, or credit card.

      Financial Policies


      Payment is due at the time or service. The amount due for services will depend on whether you have insurance, are self-pay, or are going through a Third Party Administrator. See below for further information regarding insurance,

      self-pay and Third Party Administrator. The accompanying adult to a minor patient is responsible for payment. For your convenience we accept Credit card, cash, and personal checks.


      There is a $25 charge for checks returned due to insufficient funds.


      While some cancellations are inevitable, cancellations with less than 24-hour notice or missed appointments (no-shows) have unfortunately become a great expense to our organization. When you call with less than 24 hours’ notice or if you don’t call at all, we reserve the right to bill you for the time we saved for you. No shows, missed appointments or changes in appointments made with less than a 24-hour notice will be charged a $50 fee for chiropractic treatment, chiropractic examinations and new patient visits. Nutrition consults will have a cancellation fee of $90.


      Our services are rendered to you, not your insurance company. In most cases we will call to verify your insurance benefits. However, the benefits quoted to us by your insurance company are not a guarantee of payment. We will bill your insurance plan and will collect any copay, co-insurance, or deductible due by you at the time or service. Any non-covered service fees will also be collected at the time of service. If your health plan determines a service to be “not covered” or is not an eligible expense under your plan. You will be responsible for the complete charge or remaining balance of the non-covered service(s). Payment is due upon receipt of that statement from your insurance company. It is uncommon, but pre-authorization from your insurance company may be required for chiropractic care in order to receive full benefit coverage. If you are not sure pre-authorization is required for your plan, please contact our office or your insurance company to verify your plan benefits. If required, an authorization must be received by our office prior to your visit. Failure to provide Galloway Chiropractic with proper authorization may result in delay or rescheduling your appointment. You will also be financially responsible for all services related to your visit.


      Please advise our office on your first visit whenever you have one of the above claims. We will work with any insurance companies/attorneys involved, but please remember that you are ultimately responsible for your bill if payment cannot be obtained from another party. If you, your attorney or the insurance company does not cooperate in protecting the doctor’s interest, we will not await payment and may declare the entire balance due and payable immediately.

      WE DO NOT accept Third Party Insurance on PI/MVA. You will need to pay out-of-pocket and we will provide your receipts for you to file. We DO NOT accept Worker’s Comp.


      Our office accepts assignment from Medicare. Reimbursement is sent directly to our office in payment for chiropractic services that Medicare will cover. Medicare will ONLY cover manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has been met. You are required to pay the deductible and the remaining fees for services Medicare does not reimburse. These non-covered services include, but are not limited to, x-rays, examinations, therapies, orthotics, supports, and/or nutritional supplements. Medicare patients are fully responsible for charges of non-covered services. Secondary insurance may or may not pay for these non-covered services. Our office completes and files the forms for Medicare at no charge. As a courtesy to you, we will bill your secondary insurance after Medicare pays.


      Failure to pay any balance due may result in your account being turned over to an outside collection agency. This action will not compromise your care.

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        Thank you for taking the time to fill out these forms. Someone from our office will be in touch with you shortly to schedule and collect the new patient deposit.

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