INTAKE ONLINE

Lets get you started…Fill this form out completely and push submit.

* Indicates required field

NAME *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

EMAIL *

HOME PHONE *

DATE OF BIRTH *

GENDER *

EMERGENCY CONTACT *

ALTERNATE PHONE *

SOCAIL SECURITY *

DATE SYMPTOMS BEGAN *

PHONE *

WHOM MAY WE THANK FOR SENDING YOU IN? *

WOULD YOU LIKE US TO BILL YOUR HEALTH INSURANCE *

YES NO

If YES, please provide the staff with your insurance card and/or any necessary forms. If you have insurance and your insurance requires:

A co-pay, it is due at time of visit.
Co-Insurance, we will bill you after payment from your insurance company.

Dr. Tanasse provides and bills for a combination of chiropractic and therapy services within the licensure. Occasionally, insurance benefits vary or different services. For example, a co-pay for chiropractic and co-insurance for physical therapy are different. Familiarize yourself with your insurance benefits. Please be aware that you are responsible for any charges not covered by your insurance.

PLEASE CHECK BOX THAT APPLIES *

Yes, I have read and understand the above. I have some questions…

AUTHORIZATIONS
A. I hereby authorize release of any medical information necessary to process this claim and request payment of insurance benefits either myself or to the party who accepts assignment.
B. I authorize payment of any medical benefit from third-parties for benefits submitted for my claim to be paid directly to this office. I authorize direct payment to this office of any sum I now or hereafter owe this office by my attorney, out of proceeds of any settlement of my case and by any insurance company contractually obligated to make payment to me or this office based upon the charges submitted for products and services rendered.
C. I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid to this office will be credited to my account upon receipt. However,I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that I terminate or suspend my care and treatment, any fees for products or professional services rendered will be immediately due and payable.

Name (acting as signature) *

Guardian Name (acting as signature) *

Date *

Submit