BEST CLINIC Insurance Verify Request form

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


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MM/DD/YYYY
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Insurance Plan / Policy*
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Subscriber ID number
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Subscriber's Name
Medicare is generally for people over 65
Relation to the subscriber*

【Patient's Condition】

Reason for treatment/examination/visit*
Which part of your body?*
Work Related Injury? (Workers Compensation)*
If Yes, you must have a claim number from your manager/HR of your company before visiting our clinic.
Auto Accident Injury?
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?*

We will call you to confirm your chiropractic coverage within 48 hours.