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If you know that your insurance requires authorization for Chiropractic services, you can save time by printing the required forms and completing them before your appointment!
Consentimiento Para el Tratamiento de un Menor de Edad
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Insurance Authorization Forms

If you know that your insurance requires authorization for Chiropractic services, you can save time by printing the required forms and completing them before your appointment!

Optum/MPN

If your PRIMARY insurance is:
The Empire Plan (NYSHIP)
Some UnitedHealthcare Plans
​Most Oxford Plans


English

All patients:
Patient Summary Form

Spanish

Paciente Forma Resumida
Choose most appropriate:
Neck Pain
Back Pain - pg 1
Back Pain - pg 2
Dolor de Cuello
Dolor Dorsal - pg 1
Dolor Dorsal - pg 2

American Specialty Health

If your PRIMARY insurance is:
MediBlue
Health First
Some BCBS Plans
Most Cigna Plans

English

All patients (choose one):
Initial Health Status (new injury)
Progress Form (same injury)
Choose most appropriate:
Neck Pain
Back Pain
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Other Forms

No Fault

English

Personal Injury Questionnaire
NF2 Form

Worker's Comp

English

Worker's Comp Questionnaire
A-9 Form

ChiroHealthUSA

English

Membership Application
Elect to Self Pay Form

Spanish

Aplicacion Para Plan de Descuento Medico
Forma de Pago del Uno Mismo
 HALLMARK CHIROPRACTIC
633 Roanoke Avenue
Riverhead, New York 11901


Call for an appointment 631.727.3795             Fax 631.727.1961
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