New Patient Registration Intake for

Dr. Nicole L. Hatt BS, DC

Dr. Austin Collar DC,

Dena Warfield-Testa LMT

Julie Shepperd LMT

New Chiropractic and Massage Patient Online Form

New Chiropractic and Massage Patient Online Form
  • Registration Information

  • Employment

  • Insured Information, if applicable

  • Located on the back of the insurance card
  • Medical History

  • Example: Headaches - weekly - last month
  • Office Policies/Agreements

    1. We ask that you call your insurance provider to verify your coverage. 2. You will receive EOB's (explanation of benefits) from your insurance company. Please compare what the EOB states as your financial responsibility vs. the amount you paid in our office. Any differences between the two should be brought to our attention. If additional amounts are due, please be prepared to pay that amount at your next visit. After reviewing the EOB, please place in into the manila folder that was given to you on your second visit, so that you will have all your Chiropractic records in one place. 3. We will file claims To A Primary Payer Only, for covered services as a courtesy and/or requirement for third party reimbursement, however, you may still be held responsible for payment should such claim be denied. 4. Deductibles and co-payments are expected at the time of service, unless other arrangements have been made ahead of time. 5. This office does not promise that an insurance company will pay for the usual and customary charges of this office, nor will this office enter into any dispute with an insurance company over reimbursement or the amount of reimbursement. 6. Our office will need to be notified immediately if there is any change in the following: Health Insurance, Patient Address, Telephone number, Coverage termination or cancellation or Any other reason that may affect third party reimbursement. 7. We allow up to 120 days before claims will be the responsibility of the patient to pay. Interest on the claims will not occur until 30 days past the patient's responsibility date or thirty days after denial of third party payment, which ever occurs first. Statements will only be sent if there is a balance due by the patient/guarantor. 8. Non-compliance for payment due will result in a $20 late payment/no payment fee per billing cycle. 9. Any monies owed to Coldwater Chiropractic & Wellness Center that become 90 days delinquent will result in legal action to collect the outstanding balance. You will incur a $150 administrative fee in addition to attorney fees, court fees or whatever fees may occur as a result of your delinquent account. These fees will total no less than 33 1/3% of monies owed. Administrative fees are non-refundable. 11. We require 15 working days, should additional information be asked from Coldwater Chiropractic & Wellness Center (i.e. FMLA and AFLAC forms, treatment notes, etc.). There is a $20 charge to the patient for each requested form or note. This fee must be paid before the requested information will be processed. 12. You have received our notice of privacy practices. 13. There is a $40 non-sufficient funds fee for returned checks. 14. If an appointment is cancelled or missed without 24-hour notification, you will incur a $20 fee. 15. All durable goods and supplements must be paid in full at the time of purchase, and may not be returned for refund, exchange, or credit.