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Insurance Questionnaire

Will your chiropractic or massage visit be covered by your insurance?

  • ***Brown Family Chiropractic cannot guarantee your benefits and coverage.
  • ***Your level of benefit coverage is a contract between you and your insurance company.
  • *** It is your responsibility to verify and make not of all visits, restrictions, and limitations.

 

To help you in ensuring you obtain accurate insurance coverage information, here are some suggested questions and information to assist you when calling your insurance providers.

  1. What is the name of the person you are speaking to about your coverage: __________________________________
  2. Date you call: __________________________________
  3. When calling, ask for “Chiropractic Benefits”
    • Is Dr. Sally Brown at Brown Family Chiropractic; 4401 Taylor Ave #103, Racine, WI 53405
      1. In Network? __________________________________
      2. Out of Network? __________________________________
  4. Do you have a copay?  __________________________________
  5. How many visits are covered for chiropractic care?  __________________________________
    1. Limit on number of visits?  __________________________________
    2. Limit on dollar amount covered?   __________________________________
  6. Are you covered for “neuromuscular re-education” and/or “myofascial release” (massage)?
    1. “Massage” Codes to Verify:
      1. 97112:  __________________________________
      2. 97140:  __________________________________
      3. 97124:  __________________________________
    2. Acupuncture Codes to Verify: 97810:  __________________________________
    3. Is there a limitation on a number of visits for neuromuscular re-education/units?  __________________________________
    4. Is there a dollar amount limitation for visits/units?  __________________________________
    5. Does the insurance count a neuromuscular re-education visit as a separate visit from the chiropractic adjustment?  __________________________________
    6. Does the insurance allow the adjustment and the neuromuscular re-education visits to be on the same day?  __________________________________

 

Please return this questionnaire on your next visit and be sure to call and update if there is any change in your insurance coverage.

 

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