BEST CLINIC Insurance Verify Request form

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B.E.S.T. Chiropractic Clinic / Dr. Yoshio Homma, D.C. Please fill out the form below to verify your insurance coverage. We accept most of health insurances.
【Fee Schedule】
First Examination and Treatments or Re-Examination and Treatments $120 and up Regular treatment $70 and up • Fees may vary by treatments provided ● Each insurance plan has a different coverage and policy. ● Your health insurance may not cover for Chiropractic care. ● We do not accept Medi-Cal of California State. This form is ONLY FOR CHIROPRACTIC

TODAY'S DATE*	MM/DD/YYYY
Your Name*
E-mail address*
Phone Number
Health Insurance Company Name
Insurance Plan / Policy*	PPO HMO POS Discount Others I don't know
Insurance ID*	Subscriber ID number
Name on the insurance card*	Subscriber's Name
Subscriber's Date of Birth
Medicare ID number (If you do have one)	Medicare is generally for people over 65
Relation to the subscriber*	Self Spouse Child Other
【Patient's Condition】
Reason for treatment/examination/visit*	Pain Discomfort Numbness Injury Accident Allergy Check Up Kinesiology Others
Which part of your body?*	Head Face TMJ (Jaw) Neck Sholder Back Hip Knee Leg Arm Elbow Wrist Hand Finger Others
Work Related Injury? (Workers Compensation)*	No Yes If Yes, you must have a claim number from your manager/HR of your company before visiting our clinic.
Auto Accident Injury?	No Yes If Yes, your auto-insurance is primary insurance therefore, most likely we will claim it to the auto insurance
Which language do you prefer to use?*	English Japanese Other
We will call you to confirm your chiropractic coverage within 48 hours.

【Fee Schedule】

【Patient's Condition】