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Who Should Fill Out Returning Patient Paperwork?

(If it's been > 6 months but< 3 years
OR you have a new condition/injury OR you've been in a car accident)

Welcome Back!

We're delighted to be your partner in health and honored that you have chosen to return to our office.

 

Whether it's been a while, you have a new condition or injury, or you've had a car accident, you'll find everything you need to prepare for your visit, including insurance information and guidance on updated paperwork.

 

We look forward to seeing you again!

Georgina says "hi"

Insurance change?

Insurance we accept:

Anthem or BC/BS (most), Aetna, All car insurance, Medicare ***MEDICARE: We are Non-Participating Providers. This means: We will file for you. You will pay us directly. ​Medicare will reimburse you (for services they deem medically necessary) 

 

Insurance we do NOT accept:

United, Cigna, Medicaid (any), Humana, Passport, Anthem Medicare, Work Compensation​

Car Accident?

​Kentucky is a "no-fault" state. This means no matter who is at fault, YOUR insurance pays your first $10K in medical expenses. This is called PIP coverage. 

Call YOUR insurance company and open a "PIP claim". Get this information:
  *  Claim #
  *  Claims Address and Phone
  *  Claim Handler Name
  *  Deductible Amount
 
​You must pay your deductible before your company will cover any costs. We also offer services that your insurance may not cover. These items, if selected for your treatment plan, are eligible for our time-of-service discounts if paid up front.

Self Pay

No insurance, no problem!

If you are self-pay, we offer discounts for payment at the time-of-service. We, also, offer many of our services as packages to save you even more!

Step 1

Click on only 1 of these bubbles to complete your
UPDATED CONFIDENTIAL HEALTH RECORD

Step 2

After you complete your updated paperwork...

** IF CAR ACCIDENT: Choose "NO" for "Have you been to this clinic before?"

Fill out the Confidential Patient Health Record

(if this is for a Car Accident, also fill out the Auto Insurance & Accident Report)

Confidential Patient Health Record - Updated

Welcome back to Fern Creek Chiropractic Center.


Please take a few moments to complete this form to the best of your ability. The information provided in this form will help us achieve the best possible outcome. Note that information collected via this form is private and protected from disclosure by applicable law.


Hint: Fields with an * are required fields. If left blank, the form will not submit.

Personal Information

Birthday
Día
Mes
Año
Identify as...
Male
Female
Other
Are you currently pregnant?
Yes
No
Unsure

Employment Information

Employment Status

Insurance Information

**PLEASE NOTE: We will verify benefits and file your insurance as a courtesy to you. However, it is YOUR responsibility to know your coverage, eligibility and, if you need a referral, to obtain this prior to your visit. YOU are ultimately responsible for your bill.

Health Insurance Carrier
Anthem BC/BS
Blue Cross/Blue Shield - other
Aetna
United (we do not accept)
Cigna (we do not accept)
Humana Medicare
Medicare (we are non-participating)
Self-pay (no insurance)
Who ELSE is responsible for your bill?
Who is primary on your insurance?
Primary's Date of Birth
Día
Mes
Año

***IMPORTANT: If this is an AUTO ACCIDENT, you will also complete the Auto Insurance & Accident Information Form.

Auto Insurance & Accident Report

Please take a few moments to complete this form to the best of your ability. Information provided in this form will help us provide the best outcome possible. Note that information collected via this form is private and protected from disclosure by applicable law.

Your Auto Insurance Information

**PLEASE NOTE: Kentucky is a "no-fault" state, which means your medical claims run through YOUR insurance company after you meet your deductible. It is YOUR responsibility to know your deductible. YOU are responsible for your deductible and ultimately responsible for your bill.

NOTE: All fields with an * are required. The form will NOT submit if any are blank.

Who ELSE is responsible for your bill?
Policy Holder's Birthday
Día
Mes
Año

Be advised that we cannot file to your health insurance unless there is no other responsible party or your benefits are exhausted. There are many services covered under auto insurance that are not covered benefits for health insurance. You are responsible for these services. If we do not accept your insurance or if your insurance does not cover all services, you are responsible for payment.

Other Person's Auto Insurance Information

Motor Vehicle Accident Report

Date and Time of Accident
Día
Mes
Año
Horario
HorasMinutos
Location in vehicle
Vehicle size
Vehicle type
Vehicle type
Travel direction
Road conditions
Time of day
Seatbelt
Shoulderbelt
Headrest
Airbags
Was the driver braking at the time of impact?
Did you anticipate the accident?
Vehicle struck
Not reported/unknown
Another vehicle
By another vehicle
A stationary object
Multiple impacts
Collision location
Did your body strike anything in the vehicle?
Areas injured in the accident
At the moment of impact
How did you exit the vehicle?
Not reported/unknown
Under own power
Assisted by EMS
Assisted by others
Was extricated
Were you ejected from the vehicle?
Your Consciousness
Were you Disoriented?
Medical Attention
After the Accident, you went:
Not reported
This office
Urgent Care
Hospital ER
Personal doctor
Home
Work
Resumed activities
Other vehicle size
Not reported/unknown
Subcompact
Compact
Mid-size
Full size
No other vehicle
Other vehicle type
Not reported/unknown
Car
SUV
Truck
Motorcycle
No other vehicle
Other vehicle travel direction
What part of their car hit your car?
Not reported/Unknown
Head on
Front
Behind
Passenger side
Driver side
No other vehicle

Diagnostic Screen for TBI

Have you experienced any of these symptoms continuing after the accident?
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After you submit this form, you will be directed to the Intake Form. This will set up your account in our system and take you to SCHEDULING.

Therapy Paperwork
(If you are planning on utilizing any of these therapies, go ahead and fill these out)

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