Serving Chiropractors and Their Patients

Forms

D. Practices and Procedures

  1. Informed Consent to Chiropractic Treatment by Atty. Dan Riegleman
  2. Patient X-ray Waiver – Release and Indemnification Form by Atty. Dan Riegleman
  3. Office Policies and Procedures for Patients with Personal Injury Claims by Atty. Dan Riegleman
  4. Notice to Patients of Options Available upon Insurance Companies Refusal to Pay a Claim by Atty. Dan Riegleman
  5. Patient’s Release/Indemnification of All Claims And Covenant Not to Sue Doctor by Atty. Dan Riegleman
  6. Payment Plan for Patient with a Balance/High Deductible Coverage by Atty. Dan Riegleman
  7. Financial Hardship Agreement by Atty. Dan Riegleman
  8. Patient’s Voluntary Financial Statement by Atty. Dan Riegleman
  9. Notice to Insurer of Waiver of Patient’s Co-payments/Co-insurance/Deductible Pursuant to Wis. Stats. §446.02(10) by Atty. Dan Riegleman
  10. Patient Consent to Chiropractic Treatment and Financial Agreement on Payment for Services (Non-personal Injury/Worker’s Compensation Patient) by Atty. Dan Riegleman
  11. Authorization and Assignment of Insurance Benefits by Atty. Dan Riegleman
  12. Patient’s Authorization for Bank Payments (“EFT” Debits) by Atty. Dan Riegleman
  13. Notices Required under the Fair Debt Collection Practices Act (FDCPA) by Atty. Dan Riegleman
  14. Patient Assignment of Medical Payments from Auto Insurance by David Michel
  15. Letter to Attorney on Selection of Patient Coverage – Non Medicare Patient by David Michel
  16. Letter to Attorney on Selection of Patient Insurance Coverage – Medicare Patient by David Michel

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