Workman’s Comp Tools > Insurance Verification Type > Workman's Comp 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 ChiropracticNemitz ChiropracticTruhlsen ChiropracticTruhlsen Chiropractic-HendricksRichard Wilson DCRiverside ChiropracticWeber ChiropracticWW AppletonWW BeavertonWW BismarckWW BloomingtonWW Burr RidgeWW Eau ClaireWW FitchburgWW Flathead ValleyWW Fort MillWW Grand RapidsWW Grass ValleyWW Green BayWW JacksonvilleWW LargoWW LouisvilleWW MequonWW North PhoenixWW PensacolaWW RaleighWW South JordanWW SpringWW SteubenvilleWW St CloudWW St PetersWW WaukeshaWW Wesley ChapelWW Woodbury (Empower Health)Workman's Comp InsuranceName of Insurance Does this patient have Workman's Comp Insurance to bill to? Yes, patient's account is set for billing to this insurance. Insurance company sends payment to clinic. No Additional comments?Attorney InformationHas patient retained an attorney? Yes No Name of Attorney Additional InformationWe will work with this attorney to supply them with the statements and records they need as they seek a settlement for this workman's comp claim.NotesDisclaimer When we call on a patient's auto insurance and verify benefits, it is not a guarantee of payment by the insurance company and may vary according to the patient's individual coverage 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 must understand that their 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 benefits.NameThis field is for validation purposes and should be left unchanged. Δ
