Patient Insurance Information

Subscriber Name *

Birthdate *

Month

Day

Year

Phone Number *

Address *

Relationship to patient *

Subscriber's Social Security Number

Employer Name *

Work Phone Number *

Insurance Company Name *

Insurance Company Phone Number

Insured's ID # *

Group #

Is patient covered by any other insurance? *

Yes

No

Second Insurance Subscriber Name

Birthdate

Month

Day

Year

Phone Number

Address

Relationship to patient

Subscriber's Social Security Number

Employer Name

Work Phone Number

Second Insurance Company Name

Second Insurance Company Phone Number

Insured's ID #

Group #

Insurance assignment, release of information, and authorization: (Please electronically sign by initialing below) *

I certify that I (or my dependent) have insurance coverage and assign directly to Simpson Chiropractic, PLLC all insurance benefits, if any, otherwise payable to me for the services rendered. If enrolled with an HMO and without the appropriate referral or authorization from my Primary Care Physician, I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize Simpson Chiropractic, PLLC to verify healthcare benefits with my insurance company; to release all information necessary to secure the payment of benefits and to authorize the use of this signature on all insurance submissions.

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Patient Insurance Information

Hours of Operation

Contact Information

Privacy Policy