Dr. Christopher W. Baldt
Human and Animal Chiropractic
Office Location:
32783 Long Neck Rd. Long Neck, DE
302-945-4575(Human)
302-945-4575 (Dog)
302-858-1275 (Equine)
CONFIDENTIAL PERSONAL INFORMATION
Name: ________________________________Date of Birth: _____________ Sex: Male Female
Address: ________________________City__________________State______Zip___________
Phone:_______________________
E-mail address: ___________________________Preferred contact: Phone or e-mail (circle one)
Employer: ___________________ Family Physician: _________________
Previous Chiropractor: _____________________________
Who may we thank for referring you to our office? ________________________________________________
*Please give the front desk your insurance cards if you wish to use your insurance*
MEDICARE (NOVITAS):
We will gladly accept assignment and direct bill Medicare (Novitas) for your services subject to their guidelines. The guidelines include: yearly deductible, co-insurance and visit limitations. If you have a secondary insurance please provide the front desk with the billing information. Co-insurances are due at the time of service.
MEDICARE ADVANTAGE PLANS:
We do not participate with all Medicare Advantage Plans...You will need to verify in-network coverage, and chiropractic benefits allowed before starting care...
INSURANCE (Ask front desk about participating insurances):
We will gladly accept assignment and direct bill your insurance carrier for your services subject to office/policy guidelines. They include: yearly deductible, co-insurance, and visit limitations. We cannot guarantee policy benefits and if your plan requires a referral for treatment it is your responsibility to obtain a referral number before beginning treatment. Patient responsibility balances are to be paid on the date that the service.
BLUE CROSS/BLUE SHIELD (Highmark Delaware only)
We will gladly accept assignment and direct bill Highmark Blue Cross for your services subject to policy guidelines. They include: yearly deductible, co-payments and visit limitations. We can’t guarantee policy benefits and if your plan requires a referral for treatment it is your responsibility to obtain a referral before beginning treatment. Patient responsibility charges are required at the time of service.
NON-INSURED PATIENTS/OTHER
If you have no insurance coverage or choose not to utilize your insurance, we will be following the following fee structure payable on the day that the services are provided:
Initial evaluation and adjustment $75.00
Follow-up treatments $50.00
Chiropractic is based upon the premise that all living things have an inborn striving to maintain health. This striving is dependent upon the proper functioning of the nervous system. When spinal joints are not functioning properly (subluxation) the nervous system is affected, thus reducing a body’s potential for health and health restoration. It is the Chiropractor’s purpose to examine the patient’s spine and correct any subluxation that exists through the chiropractic adjustment. Chiropractic does not offer to diagnose, treat or cure any diseases and I have been counseled that there are certain inherent risk associated with treatments. Chiropractic is not a substitute for medical care and I will direct any Medical question or problems with my Medical Physician.
I have read and agree to the above and I authorize Dr. Christopher W. Baldt to release any information that is needed to process my claim. I hereby assign my insurance benefits to be paid to Dr. Christopher W. Baldt. I am aware and agree to be financially responsible for all non-covered services.Signed: _____________________________________ Date: _________
