Workman’s CompStaff Forms » Chiropractic Insurance Verification » Workman’s Comp"*" indicates required fieldsToday'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-HendricksRiverside ChiropracticWeber ChiropracticWW AppletonWW BeavertonWW BismarckWW Burr RidgeWW CoralvilleWW Eau ClaireWW Eden PrairieWW 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)Workman's Comp InsuranceName of InsuranceDoes 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. NoAdditional comments?Attorney InformationHas patient retained an attorney? Yes NoName of AttorneyAdditional 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.EmailThis field is for validation purposes and should be left unchanged.Δ
