Patient Forms

PATIENT FORMS DOWNLOAD

New patient Intake Form

New patient intake form

COVID-19 Pre-screen Form

COVID-19 Pre-screen Form
Editable Word doc

COVID-19 Pre-screen Form
Printable PDF

Direct Billing Patient Consent forms

Patients need to give their consent before Huntington Chiropractic can start submitting claims or predeterminations on your behalf. To obtain consent, Huntington Chiropractic and the patient need to fill out and sign two short forms found below before submission of the first claim on eClaims. We only need to do it once per patient.

Note: We will retain the two completed and signed forms (either paper or electronic) in the patient’s file for two years following closure of their file.

BENEFIT ASSIGNMENT FORM

Must be filled out once per patient if the claim payment will be assigned to Huntington Chiropractic.

ELECTRONIC TRANSMISSION AUTHORIZATION/CONSENT FORM

Must be filled out before Huntington Chiropractic submits the first eClaim on the patient’s behalf.