Insurance Tools > Insurance Verification Type > Insurance Today's Date* MM slash DD slash YYYY Patient Name* First Last HiddenPhone*HiddenEmail* Clinic*Choose a ClinicBalanced Living ChiropracticCoulee HealthErickson ChiropracticHendricks ChiropracticHome Team ChiropracticHonchel ChiropracticKaizen ChiropracticModern Spine Health (Richard Wilson)Nemitz ChiropracticRestore Spine and Wellness (Mequon)Revive ChiropracticTruhlsen ChiropracticTruhlsen Chiropractic-HendricksWeber ChiropracticWW AppletonWW BeavertonWW BismarckWW BloomingtonWW Burr RidgeWW Eau ClaireWW FitchburgWW Flathead ValleyWW Fort MillWW Grand RapidsWW Grass ValleyWW Green BayWW JacksonvilleWW Lake MaryWW LargoWW LouisvilleWW MariettaWW North PhoenixWW PensacolaWW RaleighWW South JordanWW SpringWW SteubenvilleWW St CloudWW St PetersWW WaukeshaWW Wesley ChapelWW Woodbury (Empower Health)Name of Insurance Company Clinic isChooseIn NetworkOut of NetworkIn Network BenefitsIndividual DeductibleAmount per yearHow much deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/Day Family DeductibleAmount per yearHow much deductible left to meet for this year?Insurance BenefitsAre the insurance benefits for spinal manipulations, exams, x-rays and therapies the same? Yes No Co-insurance/co-pay that patient must pay per visitAfter deductible is met:Choose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate? Dollar amount?Spinal Manipulations - After Deductible is MetCo-insurance/co-pay for spinal manipulationChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate? Dollar amount?Exams/re-exams - After Deductible is MetCo-insurance/co-pay for an exam/re-examChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate? Dollar amount?X-rays - After Deductible is MetCo-insurance/co-pay for x-raysChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/No co-pay due% of the allowed in network rate? Dollar amount?Therapies - After Deductible is MetCo-insurance/co-pay for a therapyChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate? Dollar amount?Co-insurance/co-pay for 97012 Mechanical TractionChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay dueNot a covered service% of the allowed in network rate? Dollar amount?Co-insurance/co-pay for 97110 Therapeutic ExercisesChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay dueNot a covered service% of the allowed in network rate? Dollar amount?Chiropractic MaximumChiropractic maximum type per yearChooseVisit limitDollar amount limitNo chiropractic maximum per year, but has to be medically necessary.Amount of Chiropractic maximumAmount of Chiropractic maximumAmount of Chiropractic maximum left to use this yearAmount of Chiropractic maximum left to use this yearPre-AuthorizationIs pre-authorization required for chiropractic care? Yes No If yes, what are the procedures for this?ChooseProvider needs to submit clinical submission form to insurance.Pre-authorization informationPre-authorization InformationOut of Network BenefitsIndividual DeductibleAmount per yearHow much deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/Day Family DeductibleAmount per yearHow much deductible left to meet for this year?Insurance BenefitsAre the insurance benefits for spinal manipulations, exams, x-rays and therapies the same? Yes No Co-insurance/co-pays that patient must pay per visitAfter deductible is met:Choose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/No co-pay due% of the charged amount? Dollar amount?Spinal Manipulations - After Deductible is MetCo-insurance/co-pays for spinal manipulationChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount? Dollar amount?Exams/re-exams - After Deductible is MetCo-insurance/co-pay for an exam/re-examChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount? Dollar amount?X-rays - After Deductible is MetCo-insurance/co-pay for x-raysChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount? Dollar amount?Therapies - After Deductible is MetCo-insurance/co-pay for a therapyChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount? Dollar amount?Co-insurance/co-pay for 97012 Mechanical TractionChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay dueNot a covered service% of the charged amount? Dollar amount?Co-insurance/co-pay for 97110 Therapeutic ExercisesChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay dueNot a covered service% of the charged amount? Chiropractic MaximumChiropractic maximum type per yearChooseVisit limitDollar amount limitNo chiropractic maximum per year, but has to be medically necessary.Amount of Chiropractic maximumAmount of Chiropractic maximumAmount of Chiropractic maximum left to use this yearAmount of Chiropractic maximum left to use this yearPre-AuthorizationIs pre-authorization required for chiropractic care? Yes No If yes, what are the procedures for this?Additional CommentsDisclaimer When we call on a patient's insurance and verify benefits, it is not a guarantee of payment by the insurance company and may vary according to the patient's individual plan when the actual claim is submitted. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service. The patient responsibility amount provided is an estimate of cost. The patient must understand that their health insurance company may deny payment for the services received. The patient must understand that it is ultimately the patient's responsibility to contact their insurance if they want to know exact chiropractic benefits.Need help understanding this document? Watch these short videos! • In Network Insurance • Out of Network Insurance Δ
