Insurance Information

Please attach images of your insurance cards below. If you do not have insurance please check the box below stating that.

Patient First Name *

Last Name *

Phone *

Email *

Date of birth

Please select the option below that best respresents your situation. *

I have Group Health Insurance and will add my card information below.

I have Medicare and will add my information below.

I have a Medicare Advantage Plan and will add my information below.

I do not have insurance and will be paying out of pocket for my services.

Primary Insurance: Please attach a picture of the front and back of your primary insurance card below.

Front of Primary Insurance Card

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Back of Primary Insurance Card

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Secondary Insurance: If you have a secondary insurance, please attach a picture of that here

Secondary Insurance Front

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Secondary Insurance Back

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Neuroinfiniti Scan

Please take a moment to watch the video on the optional scan that we perform on the initial visit here: https://thechiroedge.com/neuroinfiniti/

After watching, please select below whether you want to add it to your initial visit for an extra $50.

Do you want to get the scan in your initial visit? *

Yes

Not sure yet, would like to chat more about it during my visit.

Please understand that if you have insurance but fail to submit it on this form, your first appointment will be treated as an out of pocket expense at our cash rates as we will not have time to verify insurance before your appointment. *

I understand

Signature *

Clear

By signing you are stating that everything listed above is true.