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

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

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